The CQC, social care and the road to privatisation

Last updated on October 13th, 2017 at 01:16 pm

We are used to seeing catastrophic headlines and quotes about the NHS and social care, but it is never very clear exactly what is envisaged in the warnings. At what point are services considered to be in complete collapse? And has it been reached in light of the failure of services documented in the new Care Quality Commission report? Do they need more than just a funding boost and what are the implications of funding being targeted more at social services than the NHS, which is the political and organisational status quo?

The State of Care

The Care Quality Commission (CQC) has published its State of Care Report 2016/17 headlined in the Daily Mirror (10 Oct 2017) as ‘Don’t let the NHS die on its 70th birthday’.

The Mirror story reports that the ‘crisis in social care’ has led to contracts being handed back to local authorities by private firms that say funding is insufficient to provide safe care…..The NHS inspections, on the other hand, show that ‘quality of care has been maintained’. The article quotes the CEO of the NHS Confederation, ‘if social care goes down, we all go down’.

The CQC report rates the NHS, social care, mental health and GPs separately. In each of those areas there is cause for concern. There is a shortage of beds in both the NHS and social care, a need for more GPs, an increase in older people with needs that aren’t being met and unpaid family carers who are struggling sometimes for years without respite.

Some of the statistics:

  • 2 million older people with unmet needs up from 1 million last year. That is 1 in 8. This has increased by 18% since last year and is a 48% increase since 2010.
  • Number of beds in nursing homes down by 4,000 in the last two years.
  • January -March 2017 highest ever acute bed use at 91.4% of capacity, when the recommended maximum for safety and effectiveness is 88%.
  • 40% of unpaid carers have not had a break in more than a year and 25% have not had a single day away from caring in 5 years. This has caused a breakdown in carers’ own health with 78% reporting a deterioration in their mental health and 68% in their physical health.
  • April – September 2016 60% of GP vacancies remained unfilled for more than three months.
  • There has been a ‘steady rise’ in people using mental health services, but a 12% drop in psychiatric nurses in the last seven years.

Total of services designated inadequate or requiring improvement:

  • Adult social care 20%
  • NHS acute core services 40%
  • Mental health core services 25%
  • GP 8%

These figures show a serious shortfall in staff and beds, ie a shortfall of inpatient provision and a lack of support and care for both older people and their carers in the community. The result is two services struggling to keep up to standard in an integrated system which is described as designed to enhance both.

NHS England’s 5 Year Forward View

The picture the CQC statistics paint is one which should cause alarm not just in itself but because of the nature of the restructuring of the NHS which is currently in progress, turning NHS England’s 5 Year Forward View into reality. The Accountable Care Organisations, the US based system being introduced, depends on more care in the community, more volunteer, friends and family and peer support, and fewer acute beds in fewer, but larger, hospitals. And despite the evidence from the CQC report being that more people are developing chronic illness, including those who currently dedicate their lives to family and friends as volunteer carers, the success of the restructuring hinges on the population having healthier lives and being more self-sufficient for their health needs.

The report lacks a thoroughgoing analysis of the structural elements which are needed to continue to provide an effective health and social care system. There is scant evidence provided that continuing down the path of reducing NHS services on a hypothetical future reduction in demand will work. Indeed, there is a contrast between the stark statistics and the report’s commentary which focuses on strong leadership, innovation and technology as the way forward rather than the underlying reasons for those statistics.

The effect of privatisation on social care

In contrast to the CQC’s report, the Centre for Health and the Public Interest’s (CHPI) comprehensive report into adult social care in 2016 looked not only at the restriction of state funding and the resulting impact on NHS services but also at the startling long-term trend of the privatisation of provision. The report suggests that whole-sale privatisation has caused significant problems that cannot continue to be ignored.  The CHPI says, “Worryingly, the early talk of a ‘mixed economy of care’ with local authorities, private and voluntary sector competing on a level playing field rapidly disappeared from political discourse.” Its statistics show the extent of the takeover by the private sector from local authority and NHS provision, “In 1979 64% of residential and nursing home beds were still provided by local authorities or the NHS; by 2012 local authority share was 6%; in the case of domiciliary care 95% was directly provided by local authorities as late as 1993; by 2012 it was just 11%.”

This trend illustrates the potential for the NHS despite arguments about the source of provision being presented as being of less importance than the headline issue of free at the point of use. The reality, in the face of inadequate public funding, is that the fees of private patients in the care system are used to cross-subsidise the public sector. Some contracts have been handed back to local authorities on the grounds that insufficient funding compromises care. It may, of course, also compromise profit.

The CQC’s statistics show that 1 in 8 older people have unmet social care needs which is a 48% increase since 2010. The CQC report does not say whether the unmet needs are greater in those who depend on public services than on those who have the means to pay. However, it is reasonable to assume that the 25% of unpaid carers who have not had a single day away from caring in five years and whose voluntary work plasters over the cracks of this collapsing system will be in that situation as a result of a lack of funds and therefore are dependent on diminishing public services. However in its 2015/16 report the CQC stated that ‘social care’s tipping point would be where the deterioration in quality would outpace improvement with a significant increase in unmet need’. Does a 48% increase in 7 years demonstrate that the tipping point has been reached?

Our concern overall is that the indicators are that we currently have a two-tier system in health and social care in this country and there is evidence that this is heavily influenced by the source of provision. As private provision expands the criteria for public services become more stringent and access to and funding for services is reduced. This analysis is supported by the CHPI’s report into social care and our own research into the rise in private income and provision in NHS hospitals since the Health and Social Care Act in 2012, reported in The Independent on 30 September NHS Privatisation Exposed: scale of treatment for paying patients at NHS hospitals revealed.

A renewal of public service

Bringing the NHS back again into the public sector (see nhsbillnow and nhstakeback for campaigns on this issue) and providing the right level of funding for the service would create the best framework for a return to the provision of universal and comprehensive services. What should be reignited – and what has been lost – is Aneurin Bevan’s principle that care should be delivered by clinical need and not ability to pay.

On the question of social care, the CHPI’s statistics on private ownership and provision of services create a more complex problem to solve. To quote that report, “There would be significant costs associated with workforce remuneration and development, as well as restoring service capacity and infrastructure to local government.” The privatisation of the NHS is less advanced than the privatisation of the social care sector. There is competence and capacity in the health sector to restore public service. But the long-term dismantling of social care capacity in local government complicates the issue. Again, to quote the CHPI, “What is more feasible is a two-pronged approach – a gradual resumption of the statutory and third sector role, and the imposition of a new, more equitable, business contract on private company providers.”

The extent to which social care is seen to be in the private sector competitive arena rather than in the public sector is illustrated in The Mirror article which quotes Alex Hayman of Which? magazine, “Our research shows a shortfall of 42,000 care home places by 2022.” If social care were primarily a public service concern we would expect this to be an issue that would be referred to the Department of Communities and Local Government but Hayman continues, “It is essential that the Competition and Markets Authority makes recommendations.”

Throughout its report the CQC recommends the 5 Year Forward View and Accountable Care route as the overall solution to the problems of the NHS and social care. But, in its failure to properly address the root causes of its own grim statistics, the CQC’s report should be taken instead as a wake-up call that the NHS may indeed not be fit for purpose by its 70th birthday. If this route is continued and the ‘mixed economy of care’ follows its current path to privatisation the evidence points to increasingly damaging consequences for standards of care and further undermining of the principle of universality.

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.