The Naylor Review – where it fits into NHS England’s 5 Year plan

Last updated on October 17th, 2017 at 10:27 pm

In June 2017 we wrote an article for the National Health Action Party about the consequences for the NHS of the Naylor Review. In light of the revelation that £220m has been raised by NHS Trusts in land sales in the last year, this article returns to the Naylor Review and where it fits into the bigger picture of the seismic changes happening to the NHS. In the background a consultation is taking place into changes in the General Practice contract to enable the creation of Accountable Care Organisations with very little fanfare.

The Naylor Review was published in March 2017. It examines how the NHS in England can raise cash from its premises. Its findings are in line with the requirements set out in the Sustainability and Transformation Plans (STPs) which were introduced in December 2015 to fast forward NHS England’s Five Year Forward View (5YFV).

Despite its serious implications, the Naylor Review attracted little attention until Theresa May was interviewed on television and made the statement that the government was backing it.

Two things theoretically under-pin the thinking behind this Review.

1) The need to free up public land to build much needed housing to solve the housing crisis.

2) The new models of care described in the Five Year Forward View have different infrastructure requirements so surplus land can be disposed of and the profits used as an incentive for Trusts to meet targets required by the Sustainability and Transformation Plans.

This blog deals primarily with the issues and assumptions raised around public land sales and asks whether Sir Robert Naylor is dealing with them honestly.

Sales of public land are not new – there has been an accelerated programme of disposals or transfers into private companies since 2010. But there are unanswered questions about the necessity of the transfers, the transparency of the deals and the value for money (or lack of it) they represent. Is there evidence to suggest that dispersing public assets into private hands is a real objective of these plans, rather than the long-term benefit to the public service?

Is the sale of public land the key to meeting housing needs?

On the morning of Theresa May’s keynote speech to the Conservative Party Conference the Huffington Post reported that according to senior party sources, Britain’s biggest council house building programme in a generation is set to be unveiled… The Prime Minister will make housing a central focus of her address as she wraps up the event in Manchester, with radical plans to use public land to embark on a new drive to creating more flats and houses.”

In the event the ‘biggest council house building programme’ was a damp squib, but £8bn was proposed for more help-to-buy, with encouragement for more private sector building. ’We, as a government, will make sure the land is available’ said Mrs May.

May and Naylor presumably assume the public will not question the need for ‘surplus’ public land, including NHS land, to be used to provide housing and that it will dampen potential objections to disposal. Current estimates are that the maximum amount of housing that could be built on released public sector land would be some 160,000 homes. This is whilst private sector developers currently own between them enough land to build some 600,000 new homes. There would appear to be no critical need for the release of any public sector land. However the release of public sector land may increase profitability for the private sector, especially if the sites are in prime locations.

Notably, it is in London that Naylor thinks he’ll find the majority of the properties that will provide the £billions he is expecting. Charing Cross Hospital in London, for example, may be reduced to just 14% of its existing area and the rest sold off for development. He has a second report on London estates, unpublished for reasons of “commercial confidentiality.”

The reality for investors looking at development properties is that central London hospitals occupy valuable sites; long derelict, small town general practice surgeries do not. Naylor’s review emphasises the combination of sales of existing estates and the introduction of private finance to create newbuilds as key to changing the estate to meet the ‘new models of care’ set out in the 5YFV.

Naylor claims that NHS land is unused and can be sold to mould the NHS into the 5YFV’s vision of accountable care.

The Review intimates that large swathes of NHS land and assets are lying around unused and that this is what will be sold off. Naylor describes the land as ‘inefficiently used’ or ‘unused’. 

This belies the objective of the Review which is set out in Section 7: property sales are to be designed with the 5YFV delivery in mind. Section 7.3.4. ‘Levers and incentives to support primary care’ says “Given the independence of the primary care sector which is largely already privately owned, active consideration should be given to how GP practices can be given incentives to move into new facilities, supported by substantial private sector investment. NHS Commissioners and regulators have considerable latent authority to insist that premises be fit for purpose. These powers could be used far more explicitly to ensure that new investment is in line with the 5YFV and to force the pace of investment in or exit from inadequate premises. (……) for example by reducing the payments for properties not meeting the future service strategy to encourage moves.”

To paraphrase that passage, GPs must move out of their old properties which they own into new ones which they will not own. They will be forced to move if they do not do so of their own accord.

Furthermore, 7.4 recommends (Recommendation 10) “STP estates plans and their delivery should be assessed against targets informed by the benchmarks set against this review. STPs and their providers which fail to develop sufficiently stretching plans, should not be granted access to capital funding, either through grants, loans or private finance until they have agreed plans to improve performance against benchmarks.”

In other words selling odd bits of land or unused buildings just to raise the money will not meet the demands of the Review. Only changes in usage of existing services will.

As Dr Kailash Chand says in his Head to Head with Sir Robert Naylor published in the BMJ (27 September 2017), “We should be standing firm against these changes before they are made and demand that there is transparency, accountability, and a thorough evidence based assessment made of public service alternatives to this proposed dispersal of public assets into private hands.” 

The private sector cetainly benefits from this increased transfer of estates out of public hands. Assura, a commercial property company, which specialises in renting premises to GPs sees NHS funding as security in times of economic uncertainty. It states in its annual report that the funding provides ‘significant growth built on a secure and long-term income stream’. Secure funding for the NHS should ensure its key responsibilities: providing a safe, high quality, accessible, comprehensive health service to the country as a whole, not buffering private sector profits from market risk.

Has the current model of the NHS failed?

The 5YFV is built on the premise that the health needs of the country have changed so extensively since 1948 that the service is no longer fit for purpose. It also states categorically that there will never again be a funding level sufficient to maintain the service as it is. This combination drives the change to an entirely different system.

Regardless of management and other changes, the basic structure of the NHS has remained largely the same since 1948. It has provided: local services in the form of GP surgeries close to home; accessible District General Hospitals providing planned and emergency integrated diagnostic, clinical and surgical services; specialist hospitals dealing with rarer conditions; teaching hospitals linked with universities developing new treatments and community ‘cottage’ hospitals offering an intermediate step between care at home and acute hospital care.

The Review emphasises the need to develop out of hospital care and to provide the necessary infrastructure to support increased care in the community. It explicitly states that it is the acute division of the service that is to be scaled back and the GP family practice model to be dismantled. Naylor argues that 57% of the cash that can be found from the sales which will pump prime these changes is in London.

The imperative to sell land is used as justification for the creation of Accountable Care Organisations, the ‘new models of care’ which will replace the traditional model and which are set to be rolled out across the country from April 2018. The assumption is that the Accountable Care Organisation structure which is being imported from the US is, as Dr Kalaish Chand puts it in his BMJ article, ‘a magic bullet’.

The Review claims that within each footprint those providers who have greater potential to raise money will share the benefits with those poorer and less well-endowed providers they are partnered with. However with the bulk of the cash being found from sales concentrated in London, it is not clear how these benefits will extend to the whole country.

Furthermore, the new models of care are experimental. Such a large-scale change without extensive consultation and testing jeopardises the NHS’s ability to provide safe care.  Historically, the replacement of traditional NHS delivery of mental health care led to disastrous consequences for patients. Yet the 5YFV relies on a similar care in the community model replacing many NHS services with an emphasis on self-care and non-clinical services.

 The GP sell off

Naylor’s analysis of the GP estate demonstrates a clear preference and expectation of mass transfer from public to private ownership and financing. Naylor himself was reported as being ‘delighted’ at the £3.3bn offer of private financing for new primary care facilities. According to the investors, the money could fund up to 750 new primary care centres but this is predicted to cost the NHS up to £200m a year in new rental charges.

Public estates are a lucrative investment for the private sector, but at the cost of a loss of available funds for the frontline care that our services exist to provide. PFI’s inflated costs are well known, but the increasing privatisation of NHS property is happening in other areas too. Property company Assura’s main NHS business is in rental property for GP surgeries. Assura declared its profits in 2015-16 as £28.8 million. Its profits for 2016-17 were £95.2 million before tax.  That’s up a staggering 230.6% in one year.

Naylor recommends exploring the use of little used regulatory powers to force GPs compliance. This is another burden on an already strained sector of the service. It raises the risk that more GPs will leave the service and exacerbate the skills shortage as a result quite apart from the huge and unnecessary cost to the NHS in rents.

So what’s it all about?

The reality of what lies at the centre of the Naylor Review is another move to privatise public assets (as opposed to services) and to simultaneously use the carrot-and-stick approach (sell and you will be rewarded, don’t sell and you will be punished) to force through the service delivery changes of the STPs.

In simple terms, the whole plan is just another version of PFI, burdening the service with more and more inflexible private property debt. This strains the funds available for service delivery whilst shaping it to fit private sector demands rather than public sector criteria.

Land sales and commercial rents being forced onto Foundation Trusts and GPs are not a way of securing the NHS’ future. It shows the strength of the desire to unlock the ownership of these assets and transfer them to the private sector that the Naylor Review recommends that Her Majesty’s Treasury should provide additional funding to incentivise land disposals through a “2 for 1 offer” in which public funds match disposal receipts. A bribe to encourage an NHS starved of funds to sell the family silver. And should the bribe not succeed there will be a penalty imposed for holding on to the assets.

Property developers should not be at the forefront of recommendations surrounding the public estate. When NHS services are put ‘at arm’s length’ we lose public ownership and control. So when a firm of international lawyers say, ‘With thanks to the British Property Federation, the key recommendations are around establishing a new and strategic NHS Property Board at arm’s length from DH [Department of Health] to act as the primary voice on estates matters.’, we should be concerned.

The Naylor Review’s vision of an accelerated sale of NHS property does not enhance health provision. Property developers stand to make profit from land acquired on the cheap. NHS Property Services Ltd has already commercialised the leases on the properties it acquired in the 2012 transfer and is implementing the imposition of commercial rents. The biggest transfer of properties so far took place in December 2016, when the company completed the transfer of the freeholds of 12 community hospitals in Devon into its ownership, with the last line of their press release stating ‘leases to regularise occupation are currently being finalised’. It is clear that in this context ‘regularise’ can only mean ‘commercialise’ and that rent increases will follow.

Although the NHS land sales are clearly being used as part of a programme of enforced change, they are not unique in the public sector. Across all departments land sales are being promoted as a solution to the housing crisis as highlighted by Theresa May in her conference speech. This appears to be evidence of a worrying trend to prioritise land values and property which give high returns to private investors over the provision of essential public services. The real risk for the NHS is that the more it moves from its core purpose, the less likely it is to be there to provide its services for future generations.

Social housing and the sale of public land – a conflict of interest?

Last updated on October 17th, 2017 at 12:16 pm

The Grenfell tower fire brought the issue of unused property into stark relief as the council failed to respond promptly to rehousing the affected tenants and residents of the tower whilst numerous properties stand empty in Kensington and Chelsea.

This week we will be looking at some of the approaches that are being taken by campaign groups and public bodies to tackle the housing crisis. We will also look at government policy on public land sales and how this relates to the housing crisis.

Oxford Professor Danny Dorling, in his book ‘All That is Solid’ endorses the view that providing decent housing is not as straightforward a matter as ‘build more’.  Prof Dorling argues that it is inefficiency in the way we run the housing market that is at the root of the problem. In reality the country has more than enough homes for everyone to have a roof over their head. Dorling’s figures show that in 2011 in England and Wales there were 66 million bedrooms for a population of 55 million. This is not to imply that no house building is needed but that the issue is not as straightforward as may first appear.

From 16 -20 October the Empty Homes campaign group are running their annual ’empty homes week’. We believe that this should be an integral part of any national housing strategy. Bringing empty homes back into use, or creating new homes in unoccupied spaces such as above shops, can be a more effective way of re-generating an area than wholesale redevelopment, which often involves displacement of established communities.

The Empty Homes campaign says,

“In many parts of England the number of long-term empty homes has come down in recent years, however there are still some neighbourhoods where there are persistently high levels. These neighbourhoods are concentrated in the North and Midlands, but are also found in the South, particularly by the coast. (There is a) vicious cycle in which neighbourhoods with high levels of empty homes tend to have higher levels of deprivation and higher levels of poor quality private rented sector housing. (….) In our view the high level of empty homes and poor standard of housing is just as much a part of the housing crisis as the extreme affordability gap in high value areas.”

The Empty Homes Campaign is building ‘a coalition of organisations championing the case for more support from central government, local authorities and others for community-led neighbourhood improvement approaches to tackling empty homes and wider linked issues.’

The Grenfell disaster has shone a spotlight onto the fact that even in central London there are more bedrooms than people. At the same time, across the city hundreds are illegally housed in ‘beds in sheds’, a phenomenon which has been going on for some years.

The government is promoting the sell-off of public land for house building. They estimate that approximately 160,000 new homes can be built on surplus public land owned by all government departments. The New Economics Foundation has launched a campaign around the sell-off because not enough socially rented homes are being created on those sites. The Naylor Review of NHS estates published earlier this year and adopted by Theresa May recommends accelerated sales to raise money for cash strapped Foundation Trusts. There are complex conflicts of interest to examine between the public and private sectors. The private sector, in contrast to the government, could provide some 600,000 homes on land which they currently own.

Theresa May, in her speech to the Conservative Party conference reiterated the government’s policy to make public land available for sale. The housing crisis is top of many people’s agenda. The sale of public land can be made into a popular crusade by those who have a genuine interest in increased social housing, but it also suits the agenda of those seeking to shrink the NHS and the welfare state.


Why we need a written constitution

Last updated on October 11th, 2017 at 02:58 pm

This blog has been written by Gavin Barker from Cornwall. Gavin addresses the issues of democratic accountability and the protections that need building into our system against undue corporate influence, to ensure the provision of our public services and to create a constitutional framework. We have included a link to We Own It‘s Public Users Bill as further material for debate on this subject.

In an earlier article, Corporate Culture, Public Services and Democracy, Jessica Ormerod documents the corrosive effect of a managerial culture of the public sector that sought to remodel public services on private sector ideals of  economic discipline. ‘Efficiency’; ‘value for money’; ‘innovation’ and ‘entrepreneurship’ became the prevaling values that guided policy making rather than human need. Citizens were re-defined as consumers and customer choice replaced democratic accountability. Education and health services were reconfigured in ways that pitched public sector providers against private companies under the disciplining hand of the market.

We now know, to our cost, just how damaging this experiment in the application of free market models has been. We have a failing education system, an NHS on its knees, rip-off energy companies, the housing crisis and rising homelessness. Beyond that, a retreating welfare state has been weaponised to attack the very people it purports to help.

What this article seeks to do is pick up on the particular point she makes on, “The cumulative direction of policy decisions since the late 1970’s…” which “has created a substantial shift in the governance and management of the state sector” over the last 40 years.

Governance and management of the public sector is inseparable from more fundamental issues to do with the rules of government which form a nation’s constitution. We are one of only three major democracies that does not have a written, codified constitution. What we have instead is an ‘unwritten’ or, more accurately, an uncodified constitution; a sprawling, opaque and antiquated collection of documents: unwritten conventions, royal prerogatives, reserve powers, over powerful executive and unelected Lords. Few voters understand the rules by which they are governed. Even constitutional experts wrestle with the lack of clarity of unwritten conventions, some of which deal with issues of war and peace! [I]  For example, who until recently had heard of Henry VIII clauses written into a proposed piece of legislation which empowers government ministers to circumvent parliamentary scrutiny?

What all this means is that the framework of governance that forms our constitution is dangerously out of kilter with basic democratic principles. Its very opacity affords too many loopholes for a self-serving political class to make up the rules of government as they go along. Their interests are closely aligned with the corporations who have benefitted so lucratively from the privatisation of public services. As such, the invasive assault right at the heart of the public sector is as much about the absence of an over-arching governing framework, as it is about a narrow free market ideology.

Five major fault lines

Before setting out how we might remedy this situation, we need to map out in more detail five major fault points that make constitutional reform so urgent. We need to expose the assumption that many people adhere to; that we already have a democracy. After all, we have regular elections, freedom of speech and assembly. We can form Facebook groups to campaign on almost anything, go on demos, write to our MP and more. But while it seems as though we live in a real democracy this is increasingly a superficial experience. Look harder, dig deeper and you will find multiple cracks and disconnections. We have the formal trappings of democracy but the substance has been hollowed out. The rules have been gamed. Free speech and the right to vote no longer translate into democratic change.

A broken electoral system

It is no longer tenable to claim that we have free and fair elections in this country. What we have is a broken and outdated First Past The Post System that once worked but now doesn’t. It worked reasonably well while we had relative social homogeneity; two broad social classes that dominated the first half of the  20th century. There was a strong white working class, union-based solidarity that broadly voted Labour and a professional middle and managerial class that voted Conservative. From the 1950’s with growing immigration, de-industrialisation and occupational diversity there was an emergence of identity politics based on feminism, race and gender. Together with a new Green politics this gave rise to a multiplicity of political voices that were not easily captured by monolithic party blocks. They wanted their own voice – and still do.

The result has been the emergence of plural party politics shoe-horned into an election system built for a two-horse race. The more political parties that stand at election time, the more the vote is split, leading to grossly distorted outcomes. For example, in Cornwall where I live, less than half the people voted Conservative but they took all six constituency seats.

The most telling fact is revealed in a joint report by Labour and Make Votes Matter: for 13 of the last 16 UK General Elections (now 14 out of the last 17 UK elections) most people voted for parties to the left of the Conservatives. Despite this we have had Conservative majority governments for most of that period. As the report points out:

“Under PR, it seems beyond doubt modern British history would have been very different. The Thatcher era of unmoderated right-wing government simply could not have happened.” (pg 24)

The report also draws on research suggesting a strong causal link between PR voting systems and low income inequality, a higher proportion of female politicians, stronger welfare states, and a more equitable distribution of public goods. But why so many positives? Researchers Birchfield and Crepaz explain these results as follows:

“The more widespread the access to political institutions, and the more representative the political system, the more citizens will take part in the political process to change it in their favour which will manifest itself, among other things, in lower income inequality. Such consensual political institutions make the government more responsive to the demands of a wider range of citizens”[ii]

The flip side to this is that corporate lobbyists find it much more difficult to push their agenda when power is dispersed across a multi-party government. There are too many people to talk to and convince, too many points at which their agenda is potentially subject to public exposure, or when agreement by one party precipitates withdrawal of support by another. They flourish best under majoritarian parliaments with one dominant party, one set of cabinet members and one prime minister.

Diminishing accountability of Parliament to the people

A dysfunctional election system diminishes its capacity to respond to and reflect diverse public opinion. Yet I suspect most people hold onto the hazy belief that there remains a workable democratic accountability to the people and that our elected representatives remain an effective forum to hold the government to account.

Look harder and you see something different. Firstly, we do not have a complete separation of powers between an Executive (government), Legislature (House of Commons) and Judiciary. It is certainly a constitutional principle we aspire to, but not one that plays out in practice. What we have is a fusion between Executive and Legislature. The government is drawn from the House of Commons and unelected Lords. While this might seem democratic and reasonable at one level, it seriously undermines the constitutional role of parliament to be an independent democratic forum that holds the government to account.

Secondly, party discipline and MPs’ career aspirations within and outside Parliament have instilled a compliant political culture and deference to the Executive. Party discipline and the Whip system has a dampening effect on independent thinking and the willingness of MPs to act according to their conscience. Moreover, an increasingly professional political class often sees a career as an MP as a launch pad for lucrative consultancy and private sector contracts outside Parliament – as instanced by George Osborne’s meteoric salary advancement through part-time posts in the city and the media. This is a problem for all parties, not just the Conservatives.

An over powerful executive

As previously referred to, the royal prerogative and other statutory powers afford government the means to circumvent parliamentary accountability.

They are relics from monarchy rule which invest exceptional and necessary powers to government ministers to act quickly in emergencies. These kinds of powers are a common feature in democracies worldwide, but are usually governed by written, codified constitutions which place limits on their use and provide mechanisms for scrutiny. Because the UK lacks a codified constitution, use of these powers goes largely unchecked, presenting real potential for abuse.

The scale of that potential is graphically illustrated in the recent proposals that form part of the Great Repeal Bill which will allow ministers to re-write large parts of EU law once these become part of UK law, without reference to Parliament. The main purpose of the bill is to put all EU law into UK law, so that on the day we leave the European Union there will be continuity. Included in the Bill are powers for ministers to amend and repeal primary legislation through Statutory Instruments – also known as Henry VIII powers.

It really doesn’t take much imagination to see the temptation for ministers to move beyond necessary technical changes and instead bring a wrecking ball to employment and consumer rights along with environmental protection.

Examples in the recent past where the government has introduced significant policy changes through such Statutory Instruments include: the abolition of university maintenance grants; allowing fracking in national parks; and major changes to voter registration [iii].

The erosion of the Rule of Law and the right to a fair trial

The Rule of Law is one of the core principles of our unwritten constitution; no-one is above the law and everyone has the right to a fair trial. In practice your right to a fair trial depends on how deep your pockets are.

This is why the recent High Court ruling on tribunal fees was such a dramatic reminder of what we have lost. It should never have been the case that people were denied access to justice on the basis of prohibitive fees, nor that it took so long to remedy this outrage. Government legislation introduced fees into employment tribunals in 2013 and this resulted in a substantial fall in the number of claims being sought – and it disproportionately affected women.

It is no accident that Lord Reed, one of the presiding judges who delivered the judgement against the government, deliberately referred to the Magna Carta, expressing the Rule of Law: “We will sell to no man, we will not deny or defer to any man either justice or right.”

Earlier examples of the erosion of the rule of law include the use of detention without trial in Ireland at various points since the nineteenth century and in Great Britain in both world wars.

The unrestrained power of Parliament

The epicentre on which these fault lines converge is the biggest one of all; the doctrine of Parliamentary Supremacy.  Parliamentary sovereignty is commonly regarded as the cornerstone of our unwritten Constitution. For many a source of pride, for Parliament had to win this power through bloody civil war and a series of constitutional crises that pitched absolute monarchical power against individual rights and freedoms. Yet while those rights and freedoms were freely given to men of property, they were only grudgingly extended to the whole population through further upheaval, mass civil disobedience and widespread protest.

The point is that the legislative power of Parliament is legally unlimited and all of its legislation must be applied by the courts. It can completely re-shape electoral rules or suspend elections indefinitely through routine legislation. There are no special additional legislative procedures accorded to laws of a fundamental constitutional nature as found in written constitutions.

Such unlimited power is dangerous. A weak House of Lords, a neutral Head of State and the absence of a constitutional court allows the executive to dominate the whole legal and political system through its party majority in the House of Commons. In effect, rather than being accountable to the people, Parliament is subsumed to the executive in what has been termed ‘elective dictatorship’ [iv].  

What can be done?

All the faults highlighted above, underline the urgency for a written constitution that sets out in plain English the rules by which we agree to be governed. This is not simply about updating the framework of governance by, for example, doing away with an unelected House of Lords and replacing it with an elected upper chamber. We must set clear constraints on the power of Parliament. Parliamentary sovereignty must be replaced by Popular Sovereignty, in the form of a written constitution, with elections at both national and local level based on proportional representation. Seats must match votes.

The obvious way forward is to convene citizens’ conventions on constitutional reform. Yet this runs up against two hurdles. Firstly, in themselves citizens’ conventions for constitutional reform hardly pose a challenge to vested interests. These are by nature, thoughtful reflective forums for blue sky thinking, they lack a hard campaigning edge. One might even hold a citizens’ convention in Parliament itself and get no more than a polite pat on the back for imaginative thinking. Parliament need not respond or take any notice of its recommendations.

The second and more serious hurdle is that to most people, the very words ‘constitutional convention’ sound remote, clunky and irrelevant in the face of more pressing challenges: an NHS on its knees, the housing crisis, and a failing education system.

But there is an emphatic connection between these crises and a failure of governance. The argument that needs to be made, not once but again and again, is that these crises cannot be resolved without reference to principles of economic, social and environmental justice; and these in turn should not be separate from the principles that guide the work of Parliament. In other words, a written constitution must also include a clear legislative framework that gives Parliament a moral compass and direction.

If the argument is made in that way, and if these governing principles are set out in a short simple charter – let’s call it a People’s Charter – it will become the hook by which a broader public is drawn into a sustained conversation about the relevance and urgency of constitutional reform. A charter of governing principles would also be the means by which to knit together the multiplicity of community and campaign groups across the country into a new collective ‘WE’. In doing so, constitutional reform gains the vital campaign momentum that a citizens’ convention lacks. This is not an either/or but a complementary strategy which is much more likely to succeed.

Brexit forms a constitutional moment

It is Brexit which serves as a constitutional ‘moment’ to commence this project. It introduced the notion of a popular sovereignty as opposed to a discredited parliamentary sovereignty. The Leave vote was not just a rejection of a remote and unaccountable Brussels technocracy, but the political status quo at Westminster. It exposed a nascent English nationalism combined with simmering regional resentments at the economic and political marginalisation of those living outside the affluent south east.

As constitutional expert Anthony Barnett has pointed out, Brexit delivered a body blow to Parliamentary sovereignty, the cornerstone of our unwritten constitution. The ‘will of the people’ overturned the will of Parliament, the majority of whose members in both the Commons and Lords voted to remain. The British public, however misled and lied to by a cynical right-wing media, made a decision mandated by referendum to leave the EU. Only a second referendum can reverse that decision. This is not about who is ‘right’, but whose will must be respected.

Whether or not that second referendum happens, progressives from across the centre left must grab the opportunity. The initiative may have to come outside traditional party structures for these are more about winning elections than changing the rules by which power is won and administered. It will more likely come from an alliance of civil society organisations that later seek to embed their agenda in party manifestoes.

A constitutional moment may be two years or a decade away but the point is to begin this process now: to plan, strategise and form alliances with the single over-riding goal of winning back the state from the grip of corporate power and inaugurating a democratic revolution.

[i] One of these is the debate over the existence and scope of any constitutional rule that parliamentary approval for military action is necessary before the government enters into armed conflict abroad. This is ongoing see Briefing Paper 12- May 2015 Parliamentary approval for military action

[ii] See pg 26 of report The Many Not The Few by Make Votes Matter

[iii] See the report ‘A Democratic Brexit’ by Unlock Democracy

[iv] This was recognised as far back as 1976  by Lord Hailsham who remarked:
The Sovereignty of Parliament has increasingly become, in practice, the sovereignty of the Commons, and the sovereignty of the Commons has increasingly become the sovereignty of the government, which, in addition to its influence in Parliament, controls the party whips, the party machine and the civil service.

 This means that what has always been an elective dictatorship in theory, but one in which the component parts operated in practice to control one another, has become a machine in which one of those parts has come to exercise a predominant influence over the rest (see Mapping the Path   to Codifying – or not Codifying – the UK’s Constitution).

Is the Commonwealth Fund’s Mirror, Mirror report a distorted lens?

Last updated on July 15th, 2017 at 04:25 pm

The NHS as a public service accessible to all is often described as one of the greatest humanitarian achievements of the 20th century. Incremental and radical changes have taken place which are putting that in jeopardy, yet a new report from the Commonwealth Fund “Mirror, Mirror 2017:International Comparison Reflects Flaws and Opportunities for Better U.S. Health Carestill rates the NHS at the top of its list of the 11 healthcare systems it uses for comparison. There appears to be a gulf between this report and the concerns of campaigners and health professionals across the UK.

It is difficult at first sight to square this report with reality. The public sector NHS is in crisis with many hospitals regularly on black alert (hospitals at full capacity, closed to further admissions), routine operations being cancelled including cancer surgery, a lack of provision of mental health services, a social care system that is collapsing due to privatisation and de-funding of local authorities, and general practice in meltdown. The Royal College of Nursing has warned that crisis is becoming the new normal. And the BMJ have published the results of an investigation showing that treatment rationing is having an increasing effect.

What the Commonwealth Fund’s report says – and doesn’t say

The Commonwealth Fund is a US private foundation which has the stated charitable aim of improving access to healthcare for America’s poor and excluded groups. It should be noted that this is not the same objective as the NHS which is designed to give universal and equitable care based on health needs not ability to pay. That is to say for rich and poor alike.

The Abstract of the report says, “The United States health care system spends far more than other high-income countries, yet has previously documented gaps in the quality of care”. The purpose of the report is to look at what lessons can be learned from the performance of other countries’ health systems. But should those lessons be taken on face value as supporting the UK government and NHS England in its objectives or the current state of the NHS? We note that Simon Stevens, CEO of NHS England, is also, coincidentally, on the board of the Commonwealth Fund.

According to the Guardian: “An NHS England spokesperson said: “This international research is a welcome reminder of the fundamental strengths of the NHS, and a call to arms in support of the NHS Forward View practical plan to improve cancer, mental health and other outcomes of care.”

But does the report deliver evidence to back NHS England’s position? The limitations of the report state:

“…despite improvements in recent years, the availability of cross-national data on health system performance remains highly variable. The Commonwealth Fund surveys offer unique and detailed data on the experiences of patients and primary care physicians. However, they do not capture important dimensions that might be obtained from medical records or administrative data. Furthermore, patients’ and physicians’ assessments might be affected by their expectations, which could differ by country and culture. In this report, we augment our survey data with other international sources, and include several important indicators of population health and disease-specific outcomes. However, in general, the report relies predominantly on patient experience measures. Moreover, there is little cross-national data available on mental health services and on long-term care services.”

So the bulk of the Commonwealth Fund’s report relies on surveys of patient and clinician experience, not clinical data.

On one count a comparison between the US and the UK turns out to be a comparision between apples and oranges, “the U.S. performs poorly in administrative efficiency mainly because of doctors and patients reporting wasting time on billing and insurance claims”. Clearly the public part of the NHS has no insurance claims, although billing between providers and commissioners is on the rise, but there is no inference drawn that the US can improve its system by eradicating insurance and the market. On the contrary the conclusion is drawn on a sample of the top three in the chart that ‘high performance can be achieved through a variety of payment and organizational approaches’. The transition from a planned system to a market system has increased the NHS’ own transaction costs significantly which is not referred to in the report, nor what if any impact that might have on service delivery. Future reports may not have such a favourable outcome for the NHS, given that this form of ‘efficiency’ is included in its assessment unless its current direction of travel is halted.

The NHS scores highly on access to services. Campaigners across the country are all too aware what loss of access means which is why they are fighting to keep their services local. The US has poor access to services and is at the bottom of the table.

But on what is arguably the most important measure of all, health care outcomes, the NHS is next to the US at the bottom of the table, so either outcomes may not be attributable to good access or other negative factors outweigh the benefits of access. The report does not address that question. Indeed of its top three overall only Australia comes out well on health outcomes, in top position on the chart. Of the other two, the Netherlands is ranked 6th and the NHS 10th out of 11.

According to the report health care outcomes “are intended to reflect outcomes that are attributable to the performance of the countries’ health care delivery systems. The measures fall into three categories: population health outcomes (i.e., those that reflect the chronic disease and mortality of populations, regardless of whether they have received health care), mortality amenable to health care (i.e., deaths under age 75 from specific causes that are considered preventable in the presence of timely and effective health care), and disease-specific health outcomes measures (i.e., mortality rates following stroke or heart attack and the duration of survival after a cancer diagnosis).”

What the Commonwealth Fund doesn’t do is to measure how changes within systems affect their rankings across systems. It also concludes when looking at the three top scorers in its report that organisational structure and funding methods have nothing to do with placings, “The three countries with the best overall health system performance scores have strikingly different health care systems. All three provide universal coverage and access, but do so in different ways, suggesting that high performance can be achieved through a variety of payment and organizational approaches.” If the Commonwealth Fund does not consider health outcomes to carry any more weight than a patient satisfaction survey, how is it defining ‘high peformance’?

Does this give us any real insight into why the NHS is in crisis, as the Royal College of Nurses have said, or explain why treatments are being rationed? Does it offer up a different kind of mirror to campaigners to see that all is not as bad as they feared? The answer is no. A ‘league table’ of the variables used to compare systems is not the same as an impact assessment of those variables on those systems. There is no analysis of the complex interrelation between the variables or any weighting in terms of which variables have most impact on the most important criterion in the report – health care outcomes.

In short the NHS is not doing well, but enough people can still access it and are still hopeful it can be fixed to keep it at the top of the chart.

One particular note of caution in respect of the statistical data drawn from the European Observatory on Health Systems and Policies is that it is from a time range of 2011-2014. For the NHS, for example, the data on Mortality Amenable to Health Care is from 2013. Although the self-reported information on care quality, access, etc, is from 2015 for the clinicians and 2016 for the patients, statistical data on the whole is from 2014 or before. This is not a criticism of the Commonwealth Fund – data collection on this scale is not instantly accessible – but because the NHS’s landscape has changed so rapidly since the Health and Social Care Act came into force in 2013 its current state may not be adequately reflected in the findings.

The positive when the mirror is asked ‘who is the fairest of them all’ is that it is good to see that both clinicians and patients still evaluate the NHS with broad approval. Despite all the claims frequently made for the superiority of other country’s systems, and the dismantling, marketistion, privatisation and de-funding that the NHS has suffered it is still highly regarded.

Even so, if you bite into the apple there is an underlying perception that there is something wrong. 44% of the UK’s survey participants said they thought the NHS system ‘works pretty well and only minor changes are needed to make it work better’. But 46% said ‘there are some good things in our health care system, but fundamental changes are needed to make it work better’. And 7% said ‘our health care system has so much wrong with it that we need to completely rebuild it’.

The changes the NHS needs are not likely to emerge from international comparisons done for the benefit of the US system. We must focus on the real issues brought to the fore by campaigners and health professionals and in so many grim newspaper headlines : de-funding, staff recruitment, training and retention, the closure and sale of hospitals and land, a management consultancy culture and ‘customer focus’ which takes precedence over clinical evidence. And above all focus on the pernicious and pervasive transformation of the NHS into a copy of the US Medicare system that is once again at the bottom of the chart.

The NHS is supposed to benefit by these changes according to its proponents yet nearly twice as many US respondents in the report as UK ones said they had had problems with coordination of services – ironically one of the major selling points touted for the system the NHS is having forced upon it.

Before celebrating the NHS being ‘No 1’, first take a bite into the apple of the survey data. We applaud the staff who are doing their best to hold everything together under extraordinary stress. The patient survey responses tell us that they are and we should welcome any report that boosts staff morale. But the health outcomes show the government and NHS England are letting the staff and everyone else down. The idea of the report as a PR and vindication exercise for them should be rejected. So when you look into the Mirror, Mirror report before you celebrate that ‘No 1’ just remember that mirrors can distort as well as reflect.



Corporate Culture, Public Service and Democracy

Last updated on July 12th, 2017 at 01:38 pm

Are governments fundamentally law makers using their legislative powers to shape the country’s social structures and balance the competing needs of the people or managers of an economy which is powered by the engine of entrepreneurship? That difference is very important to the delivery of public services and has been at the heart of the change from the Attlee government creation of the NHS and the Welfare State to our modern system of public management. But is this form of management the effective system it claims to be or has it compromised democracy and accountability as the corporate sector has been enabled by the changes to move closer to the decision-making centres of government?

The cumulative direction of policy decisions since the late 1970’s has created a substantial shift in the governance and management of the state sector. Instead of headlining the need for an expanded health and education sector to meet the growing needs of the population, for example, electoral and manifesto commitments have focused on the need for ‘economic discipline’ and ideas of consumerism and efficiency leading to lower deficits and debts. In our current times that translates directly into plans to shrink the state to fit notional macro-economic demands rather than to address the real needs of the population.

Key elements of this managerial state include the creation of autonomous agencies and devolving budgets and financial control. It has also involved the creation of ‘market competition’ in services which are monopoly or monopsony providers like the NHS and competition in the provision of the services themselves e.g. treating the private and public sectors as businesses on an equal footing and allowing them to bid for public contracts rather than planning their delivery through purely public systems.  This has meant not only an increasing emphasis on performance, outputs and customer orientation rather than population needs, but a rise of the management consultant as a necessary adjunct of government. Dealing with the private sector on large scale and complex tenders is not a skill of the public sector civil service. But to fulfill this function US consultancies such as McKinsey and Bain are used and they serve two clients: government and global corporations.

This matters because all governments for the last 40 years have followed this pattern and it compromises those who may wish to challenge the status quo. When Jeremy Corbyn faced Theresa May across the dispatch box in the first Prime minister’s questions after the general election, he should have owned the debate. In the back and forth that took place on the subject of the tragic loss of life of Grenfell Tower the question of accountability was inevitably raised.

Jeremy Corbyn set out his case along lines which attacked current government policy: 40% cuts to local authorities’ budgets, cuts and a pay cap strangling public sector jobs that have led to 11,000 fewer fire fighters which have disastrous consequences for us all. In short, as Corbyn summed up, ‘What the tragedy of Grenfell Tower has exposed is the disastrous effects of austerity.’ He went further to make demands on new regulations and the provision of resources to ensure that people are safe in their own homes.

There can be no disagreement that changes need to be made and a serious review of the legislation around fire safety is essential as a matter of priority.

But instead of attempting to defend her government’s agenda, Theresa May turned to her Right Honorable Friend and, with her characteristic smirk, informed him, the house and the country that the changes to legislation that removed the requirement to inspect a building on fire safety from the local fire authority – usually the fire brigade – to a responsible person were made by a Labour government; by Blair’s government.

12 years ago, Barroness Andrews, who presented the new legislation for Regulatory Reform (Fire Safety) Order 2005, announced the changes, ‘Business and government have agreed that that the law needed to be streamlined.’ She goes on to say, ‘[The Act] will, for example, remove the requirement for some businesses to obtain a fire certificate from the local fire and rescue authority.’ The laws that took effect in 2006 ended the practice of routine fire service inspections and passed responsibility to local councils. But it is in her assurance that business and government have agreed that we should look more closely.

It is this point, as Theresa May so carefully pointed out, that has been developing for decades and under governments of all colours – namely the outsourcing of public services to the private sector and the deregulation for the benefit of business and at the cost of accountability for the rest of us.

Perhaps most important of all is the ensuing democratic deficit. For all of Jeremy Corbyn’s impassioned demands for justice and for redress, he was ultimately unable to bring the government to account. Theresa May side-stepped any acknowledgment of guilt by passing the responsibility straight back across parliament. In fact, she left her political side-swipe til last thus ensuring that Jeremy Corbyn did not have the opportunity to respond. Such is the political game-playing of Prime Minister’s Questions. But what would he have said if he could have responded? There is no defense for his own party’s role in the degrading of the public sector.

New Labour made an art of blurring the lines between private and public ownership. It was Blair who introduced Academies into our Education system against the advice of many teachers’ unions who believed amongst other fears that the system would increase inequalities. They were shown to be right when the Academy Commission published its damning report in 2013. The report asserts that ‘all publicly funded schools should be placed within a common administrative and legal framework’, which sounds remarkably like a suggestion to return to the original publicly provided Education system.

Despite a growing body of evidence that Academies undermine equality and do not necessarily improve results for children, the policy has been accelerated. Lord Harris, a Conservative peer, has been handed acres of inner-city London land on which to build an ever-increasing number of his own brand of primary and secondary schools (41 at present) – none of which have to follow the national curriculum and all of which are built on land that was once publicly owned. Despite the evidence-based research that has concluded that the system is flawed and is unsustainable, the Conservative government appropriated Blair’s infatuation with privatising the public sector and pledged to convert all schools to Academies. But the chief architect of these policies under Labour was Lord Adonis who has just admitted to the catastrophic failure of tuition fees (another ‘politically diseased’ Labour policy).

It was Blair and Brown who were responsible for the expansion of rotten PFI deals which has diverted £billions of public sector revenues into the private sector. It was their introduction of the internal market that opened the door for global healthcare corporations stepping into our ‘national health service’ which is now wide open to the global marketplace as a result of the Coalition’s Health & Social Care Act.

Businesses have always stalked the halls of Westminster, not only as lobbyists but as advisors. McKinsey have advised governments on both sides of the Atlantic since the 1920’s. Harold Wilson’s government believed in the modernizing influence of such consultancies. His then Trade Minister Tony Benn, beloved Left-winger with national treasure status close to the adoration received by Corbyn today, welcomed McKinsey and Conservative Keith Joseph used them to help re-design the NHS in 1972, leading to McKinsey giving evidence to the Royal Commission at the end of the 70’s advising that the NHS was broken and that charges should be brought in. Fortunately at that stage their advice was not acted on.

New Labour’s era ushered management consultancies and business men right in to the heart of government and the writing of legislation. McKinsey wrote the Health and Social Care Act 2012 that has denationalised the NHS.

Price Waterhouse Coopers proudly claim to bethe leading advisor to the government and public sector’. But as the Public Accounts Committee said of PwC in 2015 they were responsible for ‘mass marketing tax avoidance schemes’ and their report (the second such in a matter of months) highlights the conflict between being advisor to two client groups with such competing interests. The PAC further said,

“The fact that PwC’s promotion of these schemes is permitted by its own code of conduct is clear evidence that Government needs to take a more active role in regulating the tax industry, as it evidently cannot be trusted to regulate itself. In particular, HM Revenue & Customs needs to do more to challenge the nature of the advice being given by accountancy firms to their clients, ensure that tax liabilities reflect the substance of where companies conduct their business, and introduce a new code of conduct for all tax advisers. Unless HMRC takes urgent action, this irresponsible activity will go unchecked, causing harm to both the public finances and the reputations of the companies involved.”

In such a role they cannot be other than an inappropriate influence on the public sector. Where profit is the primary force (as is necessarily the case in business) the values and social purpose of education, prison services, health can only come second.

After generations of private influence over public sector decisions, it will come as little surprise that the CEO of the cladding company who provided the flammable and toxic cladding to KCTMO, the tenant management organization for Grenfell Tower, is on the Building Regulations Advisory Committee (BRAC). Mark Allen is listed as Technical Director Saint-Gobain Delegation UK and Ireland on parliament’s website. The committee itself has been criticised by fire safety experts for being “heavily weighted towards the building industry” and has proved “difficult to engage with”

The reality is just as Theresa May said, both colours of government are responsible for the outsourcing of our public services to the private sector. It has been with cross-party agreement that red tape has been cut meaning a degrading of health and safety laws that are designed to prevent avoidable catastrophes such as the devastating fire at Grenfell.

As George Monbiot revealed, even while the fire at Grenfell blazed an organization called the Red Tape Initiative, chaired by Conservative MP Oliver Letwin, met to discuss ‘whether rules determining the fire resistance of cladding materials should be removed for the sake of construction industry profits.’ This initiative is a government-backed organization that includes several members from the neoliberal privately financed think tank Policy Exchange and it is largely dominated by industry alongside some representatives from NGOs and Trade Unions.

The Red Tape Initiative on the front page of its website states that, ‘Brexit presents many challenges for Britain and its businesses. But it also provides us with an opportunity to cut some of the bureaucracy that has impeded business and made lives more difficult. The Red Tape Initiative (RTI) will identify the most important, least controversial opportunities for cutting red tape in a post-Brexit world.’ Yet another example of business replacing genuine experts in the shaping of policy. In this case a self-serving group tearing up the fire safety standards in order to improve profits for industry.

At the end of the day until Corbyn starts talking about the damage, the cost, the degradation caused by the ushering in of the corporate sector into national and local government decision-making the change he promises will remain out of reach. Until we have a government that truly values the integrity of public services we will not be able to even start to restore the vital protections that a true public sector ensures. And until our public services are made public again there can be no democratic accountability. At the dispatch box on 28 June the dead of Grenfell Tower were nothing but a pawn in a political game of cat and mouse. The work of the opposition must include a clear program of creating a modern public sector within a cradle of public ownership, provision and accountability. The elephant in the room of direct corporate influence in Westminster and Whitehall cannot be avoided.