Darzi – a privateer through and through

Darzi’s national proposals on NHS ‘reform’ are as nasty as his London plans. The theme of privatisation runs through the proposals just as plainly as the letters in a stick of Blackpool rock.

The document here was my contribution to developimg the formal Unite (Amicus Section) response to the national consultation on Darzi’s proposals:

Response to national Darzi consultation

Gift Horses – Look very, very closely

 Sometimes, trade unions make mistakes. One of the biggest mistakes made by our NHS unions was support for Agenda for Change.

AFC was the new pay and conditions deal that was introduced in most health trusts in 2005 (with an official start date of October 2004). Members were promised huge pay increases – but mostly didn’t get them.

A fair proportion of our own members got pay cuts. The Union did a comprehensive survey of the outcomes for our members at so-called ‘Early Implementer sites’ – and then decided the findings were too scary to publish!

Most members also ended up with an increase in working hours. We’ve seen a steady ‘dumbing down’ of grades since the new system came in. We’ve got groups of members being picked off one by one – the first round of losers back in 2004/05, the members losing through changes to unsocial hours payments now, and the members who will almost certainly lose through cuts to on-call pay in a few months time.

Our members in Northern Ireland are currently in deep trouble. AFC is only now being implemented – years after it was done and dusted in England. In Northern Ireland, there’s a strange process going on that means telling NHS workers that they owe the Government a load of money and they have to pay it back!

First jobs are matched in a supposedly careful and scientific and fair process to decide how much money they’re worth – and then they go to ‘second matching panels’ which in some cases just arbitrarily slash the pay decided first time around. We’ve got members facing massive and immediate cuts in pay – hundreds of pounds a month, in some cases.

Then along comes the ‘Recovery of Overpayment Provision’. Members are told they have been overpaid since 1^st October 2004 (because that’s when the big pay cuts should have applied), and that they therefore owe the Government a pile of money. Employers are now deducting this from pay packets without even bothering with the niceties of asking people. Health workers are facing real financial crisis. I’ve heard from one family expecting to lose their home.

Unite needs to pull its finger out and get this sorted – as does every other NI health union. The treatment of these NHS workers is an absolute disgrace. It’s time for the Union to send a clear and simple message of ‘No, we’re not having it’ – with a willingness to back this up with whatever action it takes.

There are wider lessons to be learned. AFC was sold to us as a great package that the Government was offering because they loved us to bits. What nonsense. We should have looked the gift horse in the mouth. Health workers – like all other workers – have only ever won improvements to pay and conditions by fighting for them. We should never kid ourselves that there’s an easy alternative.

Independent Sector Treatment Centres – a waste of OUR money

Apologies for not posting for a bit. A nasty bout of norovirus was to blame – I recommend not getting this!

Secretary of State for Health Alan Johnson likes to face both ways at once in public, when it comes to privatisation of the NHS. Late last year, he dropped some planned ‘Independent Sector Treatment Centres’ – but approved others. At the same time he moved swiftly on with the privatisation of primary care (i.e. GPs and other community based health services).

There’s an interesting summary here of Allyson Pollock’s latest research on Independent Sector Treatment Centres: http://www.bjhcim.co.uk/news/2008/n802034.htm

The private sector likes running ISTCs. They’re able to cherry pick the younger and healthier  patients and the low-cost surgical procedures like cataract operations and knee replacements. NHS providers, by contrast, bear the cost of complex patients and of training staff.  The NHS has spent £5 billion so far on ISTCs  – and big business has made an awful lot of money. Of course, we can’t be told the detail of private sector contracts or profits, because of ‘commercial confidentiality’.

Pollock and her colleague review the evidence around ISTCs. Interestingly, ISTCs have conspicuously failed to collect data on their performance. The NHS has to – ISTCs just don’t bother. So we spend £5 billion of public money, without any clear idea of what we get in return. It is impossible to reliably assess the quality of care, because they won’t tell us! Anecdotal evidence, though, is of worse patient outcomes.

ISTCs were meant to provide ‘additional capacity’ – just supplementing the NHS a bit, rather than replacing it. In fact, they poach staff from the NHS, and – by taking away NHS ‘business’ – threaten the viability of NHS hospitals. They also get paid whether they do the work or not – a very neat trick.

Astonishingly, ISTCs even manage to land the NHS with liability for clinical negligence claims, even though it’s the private sector provider that has made the clinical mistake.

I’ve been looking at Darzi’s proposals for London healthcare this weekend. Interestingly, a lot of the plans seem to be about bundling up services into packages that will be attractive to the private sector. Virtually all high-volume planned surgery will be stripped out of hospitals and carried out at new ‘elective centres’. Darzi isn’t explicit about these being private sector enterprises, but they look exactly like ISTCs with a slightly different name.  The NHS continues to be broken up at frightening speed.

And Alan Johnson’s real views on privatisation? Here’s a quote from a Ministerial Statement issued in November 2007, and a good one to remember the next time we’re told he’s very careful and cautious about privatisation:

“The Independent Sector is playing an important and increasing role within the NHS, providing high quality treatment and choice for patients, and innovation, dynamism and contestability for existing NHS providers.”

He’s right about the ‘increasing role’, but dangerously wrong on absolutely everything else.

Darzi plan to extend working hours

I’m working at the moment on the Unite (Amicus Section) response to the London Darzi proposals. One of the interesting little details is the huge attack on the working patterns of health workers – something that has gone almost unremarked.

Health workers have always accepted that they will work unsocial hours when there’s a clinical need to do so. Hospital in-patients very obviously need care 24 hours a day. Hospitals can’t be closed down so that all the staff can go home.

However, most healthcare isn’t hospital-based – it’s ‘primary care’. That means appointments in a community setting with GPs, practice nurses, health visitors, district nurses, physiotherapists, speech and language therapists and so on. Primary care appointments account for about 80% of healthcare contacts. GPs and practice nurses will offer early evening appointments, but most primary care staff work pretty much a standard day.

The plan is that all of this primary care (and a load of the outpatients appointments now offered in hospitals) will be shifted to big primary care ‘factories’ called polyclinics. There are a lot of problems with these, around access, privatisation, the closure and running down of hospitals and so on (which I’ll cover more fully another time).

The shift to unsocial working hours is a big deal, though. All polyclinics will open between 18 and 24 hours a day, 7 days a week – with all the implications for support staff and clinical staff that go with that. All community services will be offered for a minimum of 12 hours a day, 7 days a week. ‘Interactive health information services including healthy living classes’ are, rather oddly, required to be available 18 to 24 hours a day. Who actually wants to attend a healthy living class at midnight or 6am? Maybe all the other health workers who are being made ill by their appalling working hours!

Darzi even talks about 40 hours being the standard working week! So much for the idea of reducing from the AfC 37.5 to 35 hours in the next pay round.

There isn’t a clinical need for this. This is about meeting the demands of the CBI that virtually no one can take time off work to attend a medical appointment. This is not in the interests of health workers – or the people who access primary healthcare.

This represents a significant attack. Our unions have got to be proactive in opposing this.

The relevant page from Darzi’s report is available here: Darzi London Report – “Polyclinic” opening hours.

A Study Day for resistance

I attended an important meeting yesterday. This was a meeting of Unite Health reps across London, intended to begin planning our strategy for resisting the multitude of attacks we face.

The meeting arose from a London Region Health Sector Committee a few weeks ago. Every single elected delegate at this had described the crisis they faced in their own Trust or organisation – and every single one of us felt we were being left to fight alone, without the backup from our Union that we needed. We agreed at the committee meeting that it was time to create a sharper, harder and more united approach to the cuts, redundancies and privatisation that plague the NHS.

Yesterday’s larger reps meeting was fascinating. We had reps there from primary care, hospitals, mental health, and the National Blood Service. The reports from every area were so similar it was shocking. Rep after rep described the pressures and insecurity caused by constant reorganisation. Job loss is a real fear for many of us (and an immediate threat for a few). Privatisation is now on the agenda for our core groups of members, with pathology services going out to tender, and primary care services in a number of Trusts farmed out to ‘Autonomous Provider Organisations’ as a major step towards outright privatisation.

Many reps raised professional issues. The loss of training, the loss of professional management, and the crude use of skill mix, come together to drive down the standard of clinical care in many services. Health visiting in particular is absolute crisis, with the steady erosion of universal services. This, in turn, impacts on other services – with paediatricians, speech and language therapists, clinical psychologists and so on picking up referrals later because children with complex health needs are not picked up through routine health visitor screening.

We also talked about politics. We discussed the conflict of interests in a union that simultaneously decides on ‘two years peace for Gordon Brown’ and that makes defence of the NHS a top campaign priority. Reps said that the attacks on the NHS weren’t coming from individual ‘bad managers’ in Trusts – they were driven by a Labour Government.  Reps were very uneasy about the Union’s support for Labour.  A Full Time Officer said that people just had to become Labour party members and Constituency Labour Party delegates, join the political structures of the Union, and influence things that way. He complained that people sounded like a ‘party political broadcast for the Conservative Party’. Reps were furious. One said she felt insulted. Another said that Labour Party membership wasn’t a condition of Union membership. The major topic of conversation over lunch was, ‘How dare he?’. Activists in our Union are very clear that we can’t defend Health without criticising the Government that is smashing our services.

The key thing, of course, is what we need to do about all this. We were talking about basics yesterday – the first step in putting together a plan for resistance. We were very clear that leaving reps to fight at local level – without information or support – is a recipe for disaster. We talked about the need to recruit and organise. We thought of ideas like a national enquiry into the state of the NHS, sponsored by Unite. We discussed the need for trade unions to work with and support community campaigns. We discussed the need to share information, ideas, accounts of the campaigns that have won and lost – and why. If Chief Executives can get together to attack our NHS, why on earth can’t we work together to defend it? And we also talked about the need for resources. If Unite values its members in Health, and especially if it values its reps and activists – it must put in the money for campaign material, and the Officer and Organiser support we need.

Yesterday was the first step, but a significant one. We’re meeting again in a month to look at what we’ve been able to deliver. The outcome matters. The NHS is melting away – trade union activists are a vital link in defending it.

Privatisation north of the border

There is not the same drive to privatisation in Scotland as Gordon Brown’s Government is demanding in England. Some of the same “market” pressures exist though.

There is an article in today’s Glasgow Evening Times exposing a plan to privatise by NHS Glasgow and Clyde. They are negotiating a deal with Capita Health Solutions to take over the NHS Board’s own occupational health team. They are supposedly looking for a more “efficient” service.

Capita Health Solutions are part of the Capita Group. Capita are best know for business process outsourcing. That’s privatisation in the NHS and offshoring elsewhere. Capita describe their vision for the NHS:

“Outsourced services and public private partnerships are increasingly seen as key to building capacity and delivering the capability and experience necessary to facilitate this change.”

It must be a profitable business. Capita is worth £4 billion.

The privatisation of occupational health in Glasgow may seem small in comparision to some of the attacks we have been facing south of the border – but it must be resisted just as strongly. It has always been a powerful argument against privatisation that Scotland has been able to provide a quality health service without it.

I hope our colleagues in Scotland can prevent this attack succeeding. The rest of us need to give them our full support.

Another Victoria Climbié tragedy on the cards?

Yesterday I had the privilege of meeting two health visitors – both of them good campaigners and serious trade unionists –  from Waltham Forest PCT. This was at Unite’s London Health Sector Conference.

The health visitors described how they campaigned a couple of years ago against a 40% reduction in the number of community nurses. They won then, through a high profile campaign, public meetings, a lobby of the Board and so on. I remember speaking at one of the public meetings at the time.

Unfortunately the victory was only temporary. Staffing levels have been reduced by stealth instead, with more and more posts just left vacant. So in health visiting, management has achieved its 40% reduction. Health visitors have been trying for many months to highlight that services are unsafe, and the Trust has been refusing to listen. Quite rightly, these health professionals have again gone public with their concerns.

Last year, 4,500 babies were born in Waltham Forest – but there are only 26 full time health visitors. This cannot be a safe level of staffing. Unite believes that another Victoria Climbié tragedy could be on the cards.

Health visiting is under threat, not just in Waltham Forest but nationally, with the number of qualified staff now at a 13 year low. Historically, health visitors have played an essential role in providing ‘universal’ services – services available to all families. Parenting isn’t easy, and most parents need support at some time. It’s also impossible to predict which families need extra help if you don’t go and see them in the first place. Universal health visiting services are being lost across much of England – and small children and their parents are suffering as a direct result.

 A 2006 survey showed huge variation in staffing levels, with caseloads ranging from one health visitor for every 160 children in Doncaster to one health visitor for every 1,140 children in Redbridge, London. I caught a BBC feature on health visiting a couple of days ago. A Department of Health spokeswoman claimed that caseloads were higher in London because London was ‘in advance’ of the rest of the country in implementing the new model of ‘targeted’ services! This is intended to be the future – families and children go without.

Waltham Forest PCT managers claim they are committed to ensuring the safety and welfare of children. Local health visitors report that cases of rickets, degenerative neurological conditions, poor diet, and postnatal depression are being missed.

Sometimes trade union and professional issues come together exactly. These health visitors – professionals and trade unionists – are doing a great job of defending the services they provide.

A link to the local newspaper coverage is here.

NHS competition ‘may damage care’

Labours support for “the market” in healthcare is based on their assumption that maket forces will bring improvements. I’ve never believed that. Now a piece of academic research confirms this. It concludes that care may have been damaged.

I’m reproducing the press release about the research in full below:

Competition between NHS hospitals may lower the quality of patient care, researchers have warned.

When hospitals are forced to compete with each other death rates from heart attacks actually rose, they found.

The decline in standards means patients are worse off even though waiting lists and waiting times have fallen, according to a paper published in the Economic Journal.

Professor Carol Propper at the University of Bristol examined the “internal market” in the NHS created by the Conservative government in 1991. Labour has introduced similar market-based reforms intended to improve health service performance.

She found deaths from heart attacks actually went up in hospitals covered by the reforms. Heart attack death rates are used as an indicator of overall hospital performance.

The decline in performance more than wiped out gains of 7 per cent from improved technology.

The paper “Competition and Quality: Evidence from the NHS Internal Market 1991-9” found waiting lists and times did fall as a result of the market reforms.

But hospitals’ overall efficiency levels fell, as managers concentrated resources on measured targets while neglecting others.

Professor Propper wrote: “In the case of competition in the English health care market, quality of care was unmeasured while waiting lists were reasonably well measured.

“The incentives of competition appear to have led hospitals to focus their effort on the easily measured activities to the detriment of the unmeasured, in the process possibly also lowering efficiency.”

Organising out of decline

Each month the London Region of Amicus Unity Gazette, the broad left grouping in the Amicus Section of Unite, holds a monthly meeting for its supporters. This month, the main discussion was about union organising.

Union organising is not just recruitment. It’s about building up a strong organisation in the workplace and the industry, with a high density of union membership, and workplace reps empowered to act for the collective interests of members. It’s about rebuilding a union organisation that declined in most areas since Maggie Thatcher’s Government launched its attack on trade unions.

It sounds basic. But there has been an argument about whether or not it is possible in today’s world. Derek Simpson has frequently argued at the NEC and elsewhere that an organising agenda is impossible. His argument is that, with globalisation, the future for unions is stabilising membership through mergers, both within Britain and internationally. He has described this as “managing decline”.

Going with this is a service model of a union. It’s almost like an insurance policy. Members pay their subs and in return they get a phone number to call if they have a problem. Full-time officers run the Union.

The weakness in this approach is it minimises the idea of a union as a collective organisation of the members where we all work together. A principle of the union movement used to be “an injury to one is an injury to all.” That is frequently forgotten with the insurance model.

The TGWU has a different approach. Their leadership believes it is possible to rebuild union organisation on the ground.

Given Amicus and the TGWU are now one union, this is a debate which is at the heart of the future strategy of our union. So the February Gazette meeting was given over to discussing this issue. For background, the Gazette Regional Convenor had circulated a document from the TGWU Organising Department describing their strategy, Organising out of decline.

We had a long discussion, In all, some 15 people spoke, many making quite lengthy contributions describing their experiences. What was a common theme was a preference for the TGWU approach over that which had been pursued by Amicus.

One of the issues which was highlighted was the changes we need to take place with the way we train our reps. A senior rep in the Not For Profit sector described how a new rep had come back from their initial one week union training course. The senior rep asked how it was. The response was “great, when can I take my first disciplinary”. The training was about representing members as individuals – not about how to build the union as a collective in the workplace.

An ex-full-time officer continued the theme. He said he had taken voluntary redundancy because he spent most of his time acting as a lawyer, representing individual members, rather than organising he had signed up for.

There is nothing wrong with representing individual members – it’s something every rep has to do every day. And it’s great when you are able to prevent a member being disciplined unfairly. The trouble is when ou spend most of your time doing this.

Many of the individual disciplinaries and grievances that come up are a result of the increasing stresses coming through constant reorganisation and increased workload. We’ve got to spend as much time tackling the big issues as we do the individual cases. That’s about involving all the members, and making sure most (or preferably all) the people in your workplace are members.

The policies of confidentiality around disciplinary cases accentuate the problem. I’ve represented members who have been suspended for months and won a verdict of “no case to answer”. It’s very satisfying, especially for the member, but also for me. It’s a secret though. Confidentiality may be necessary in many cases. It does howver prevent the union from publicising the victory and, perhaps, suggesting that the issue, for example, was under-staffing raher than staff error.

When we do act collectively we can win. Unite members stuck together during the last reorganisation at my Trust. We were initially faced with over 100 jobs under threat. In the end we lost only a handful, mostly through voluntary redundancy. At each stage union members acted together. When the Trust sent out letters to individuals, it was usually the union that responded – reducing the pressure on individual members. Every step in the process, the Union exerted its collective strength. Not a 100% victory, but far from a defeat.

The TGWU model is not perfect. I believe though that it’s a good starting point for what we should be doing in health. In London, only 50% of health workers are in a union. We need to up that percentage. We don’t have enough reps. The issues are there. Privatisatiion, centralisation, and cost cutting, all threaten staff no matter what their grade or professional grouping. There is a need for a strong union. A TGWU-style oranising campaign wouldn’t be a bad start.

Trip to Cuba

Rarely for me, I missed yesterday’s Amicus NEC meeting because of union commitments in my Trust. With the merger proceeding, more and more decisions are being taken by the Joint Executive. I didn’t expect to miss any crucial discussion or votes.

I have had some reports of the meeting from fellow EC members and now wish I had been there.

Apparently the Union had received an invitation to attend the May Day celebrations in Cuba in 3 months time. I am not opposed to sending a small delegation, perhaps combining the trip with a look at healthcare or education in Cuba. That’s not was proposed though. The proposal was that all members of the NEC be invited to go on the trip. That’s around sixty people. I don’t know how much that will cost, but I can think of many better uses for members’ money.

Thankfully, one solid left-wing activist on the NEC argued against the proposal. It was nevertheless agreed overwhelmingly.

I, for one, won’t be accepting the invitation. I never even claim the £25 ‘beer money’ that NEC members can get for simply attending a meeting.

I believe NEC members are elected to represent their members’ interests. They should not need financial incentives or ‘free’ holidays – paid for by the members. For me, it has been a privilege to serve on the Amicus NEC for the last four years, fighting for our members in Health.