The NHS is dying, pretty well exactly as I said it would some two years ago now:
Some scandals may emerge in time over ‘backhanders’ paid by the private hospitals to the private commissioners, and in some circumstances it will turn out that the people doing the commissioning are simply commissioning themselves in another name – the whole inefficiency of which the provider-purchaser split was supposed to stop – but it will all be a bit esoteric and complicated for people to understand, and there won’t be much of a fuss.
In fairly short order, we may get these new commissioners creating two tiers of provision from within GP surgeries, with one level of care for those not paying, and those who just happen to have signed the relevant insurance policy forms, which just happen to be in the GP surgery.
Insurance-based healthcare, and the exclusions that this brings, will come not through a government announcement, but by the surgery backdoor……
The consortia [now called CCGs] will end up being led by two or three ‘movers and shakers’ in each area, whose job will be simply to negotiate a decent deal for their colleagues and let the private commissioners get on with the rest. There will be no revolt in primary care, and in secondary care no-one will actually notice till it’s too late.
Two years on, it’s being more widely recognised that, as of 1st April, the NHS privatisation will being quietly but in earnest, as the section 75 regulations kick into gear, Clinical Commissioning Groups with often overwhelming direct financial interests in private providers put services out to the market, public provision withers on the vine or simply goes bust, and private insurance arrangements start to become the norm, initially for (the more profitable) elective healthcare, and then for the rest. As Lucy Reynolds from the London School for Hygiene & Tropical Medicine rightly notes, what comes next in this wildly ‘imperfect’ market is market abuse and health cost inflation. This inflation around the ‘cherry-picked’ services, Lucy might also have noted, will lead to the stripping of resources from the less profitable services – no health budget ring-fencing will protect that.
So what is to be done? By 2015, if and when Labour regains power, the promise of a repeal of the Health & Social Care Act (and the accompanying Section 75 regulations) may be a welcome statement of principle, but it will not significantly change the way in which services have already been privatised, seemingly irrevocably. In many cases, there simply won’t be the public services to transfer them back to, and the incoming government is likely to consider the full-scale implementation of NHS II a little too much of a fiscal challenge, even if the recreation of the cumbersome institutions of 1948 were desirable.*
What Labour can do, though – and needs to start thinking through now – is to tackle the local institutional architecture, in a way which creates the platform both for the establishment of local democratic control of both the type and quality of provision. If it gets this right, this might actually lead, in the medium term, to a better health service than we currently enjoy – as I’ve noted before, it does not become Labour to gloss over the very clear health and social care failings caused by the managerialist ideology that has held sway for the last thirty years.
More specifically in terms of local institutions, the Labour government-in-waiting should first consider retaining the Clinical Commissioning Groups. but diluting the power of GP practices within them by making theirs a minority voting position, through the introduction of members of Foundation Trust governing councils (increasingly focused on quality standards if the Francis Inquiry recommendations are carried through) along with elected councillor representation in keeping with Councils’ new public health function. The immediate impact of this is likely to be presumption against private sector provision where other options still exist (they won’t in many places).
Second, the Labour government in waiting should commit to ensuring that these new-style CCGs adhere both to the letter and spirit of the Public Service (Social Value) Act 2012 under which all CCGs (and the NHS Commissioning Board), have a duty to consider:
(a) how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area, and
(b) how, in conducting the process of procurement, it might act with a view to securing that improvement.
(Oddly, this is Tory legislation, aimed primarily at breaking the perceived monopoly power of local authorities, but can be used to the same effect against private sector dominance in healthcare provision. That will really piss off the Tories….)
These two relatively simply steps will set the direction of travel back against wholesale privatisation, although of course attempts to terminate contracts are likely to result in lengthy and quite likely unsuccessful legal battles, so early progress is likely to be quite slow.
Nevertheless, institutional change at local level by government, especially if accompanied by moves within the Labour party and the broader movement to re-energise Trade Councils, in a move away from the vapid Tory ‘consumer localism’ and towards a quality-oriented ‘worker localism’**, could provide early impetus for the creation of a properly socialist health and social care system – a system fit for the 21st century (whether or not this is tax-based or progressive social insurance based doesn’t really matter as long as it provides for equitable provision) , with private operators increasingly steadily cleared out in favour not just of direct NHS Trust delivery, but also a new surge of worker co-operatives (although charities and social enterprises may also play a valid part).
* It is always worth remembering, in the context of the fetishisation of the 1948-style NHS, that until very late in the day a radically different – and I would argue preferable – NHS structure was being argued for. This was a much more decentralised and locally accountable system, rather than the monolith we grew to love despite it tendencies to managerialism (and I would argue that this is why service standards have declined in the NHS faster than in local authorities, say). See Rudolf Klein’s seminal The Politics of the NHS for more (the later edition is called The New Politics of the NHS but the early chapters are the same).
** This is not to argue for the introduction/retention of localised terms and conditions. Trade unions should of course be encouraged to negotiate at national level, and a properly brave/strategic Labour government would use the need to ‘renationalise’ the NHS, and to invest quality in the hands of its staff (as opposed to its bosses) as a rationale for the relatively painless (in terms of reactionary public opinion) repeal of restrictive trade union legislation. Frankly, I’m not holding my breath on this one.
The online social enterprise community – of which I may now well be an honorary member – has had some debate about the importance or otherwise of the Secretary of State for Health’s recent definition, for the first time in English law, of what it is to be a social enterprise, which I covered here, and originally here.
David at Beanbags and Bullshit gives links and a good overview of the debate, which boils down to different views on whether the definition set out in the new Healthwatch regulations will come to act as precedent, replicated in other legislation and in broader NHS (and other departmental) policy, or whether it’s strictly focused on the very narrow, and relatively unimportant issue (given their lack of real power) of who will get to run Local Healthwatches.
To date, my own position on this has been simply “I don’t know”. On the one hand, it has been difficult to work out how exactly this new definition might be used as a lever for privatisation of NHS services. On the other, it’s a puzzle as to why the Department of Health would go to so much trouble expanding the usual conception of social enterprise to include private firms as long as they don’t take out more than 50% from profits in any one financial year, unless there was some kind of plan to expand its use beyond the financially unimportant Healthwatch scheme.
However, the news emerging about Monitor’s Fair playing Field recommendation, that private health firms should become exempt from corporation tax on their NHS profits, has me leaning a little towards the latter interpretation, namely that the Healthwatch regulations form part of some devilishly clever scheme.
I find it difficult to believe that Osborne will find it politically feasible to stand up at the next budget and announce this new tax break in the face of a popular swell against tax avoidance, however much it might be sold on the grounds that Any Qualified Provider private firms currently suffer from unfavourable cost terms when compared with the NHS itself. That would surely be too risky as a confirmation of whose side the Tories are on.
But if the tax break is dressed up as an incentive for social enterprise, tapping into the government fairly well developed narrative on the virtues of mutualism and pointing to existing ex-NHS staff mutuals as an example, but conveniently leaving out the detail of how social enteprises are legally defined nowadays, Osborne, Hunt and the private health lobbyists may well feel its worth a go as part of the pre-election scorched earth strategy.
Or maybe that’s a conspiracy theory too far. I still don’t know.
If I’m right, you heard it here first. If I’m not, then it’s simply the usual omnishambles, ok?
ps. I ‘m thinking of doing a Freedom of Information request on the consultation responses and meetings which fed into the Healthwatch regulations, to try to ascertain to what extent the private health lobbyists were at work. Has anyone else reading this done one, or are they interested in doing so?
Economist commentator Daniel Knowles seems surprised:
This is bizarre – do Tories not understand that housing benefit is ALREADY determined by geographical location? http://www.telegraph.co.uk/news/politics/conservative/9782816/Tory-manifesto-blueprint-lower-benefits-for-Northerners-and-longer-school-days.html …
He’s referring to the Telegrpah’s coverage of new report to Osborne from the Tory righwing 2020 group Agenda for Transformation, in which:
One of the report’s most controversial suggestions is introducing different levels of welfare payments around the country. House prices, travel fares and some other living costs are significantly higher in London and the South East than elsewhere.
I’m not sure why Daniel’s so suprised, other than the obvious reason: he’s not been taking much notice. The proposals for variable welfare payment rates across the board date back at least to 2009, when Tory Essex County Council submitted a formal proposal under the Sustainable Communities Act 2007 for devolution of benefit eligibility- and rate-setting powers to local government level. They submission argued:
As this proposal seeks to tackle worklessness it will be essential that control over the eligibility criteria and payment rates for Job Seekers Allowance, Income Support and Employment Support Allowance be transferred to ECC. This would put us in a powerful position to tailor the most important work-related benefits to local market conditions and ECC skills and training programmes.
The 2020 group’s recommendations are simply an attempt to push through this long-desired localisation of all benefits. As Carl has predicted (though I think he might have been copying), 2013 will see the rise to real power of the far right within the Conservative party, as electoral defeat looms, and Gove and his allies set their agenda for opposition.
This shouldn’t be a surprise: it’s been coming for a while.
Brandon Lewis, Parliamentary Under Secretary of State for Communities and Local Government, gives his reasoning for the decision to bar local councillors from the Local Government Pension Scheme
Robust local scrutiny of council spending requires councillors to be substantively independent of means
I wonder if there’s any evidence of councillors not being robust because they’ve had pension rights.
Interestingly, this requirement does not apply to Boris Johnson, who gets to keep his pension rights because he’s full-time.
On Friday, the regulator Ofqual released its 133 page report into what happened with GCSE English this summer. I skim read it then, but couldn’t quite believe my eyes at some of what I skimmed, so read it more thoroughly over the weekend. I now believe my eyes; it’s Ofqual I don’t believe.
Ofqual argue, in essence, that thousands of students got lower than their predicted GCSE English grade this summer, not because grading boundaries were radically and unfairly revised between January and June 2012, but because teachers tend to “overmark”. This is the key graph Ofqual uses for that argument (this one is for the AQA exam board but the one provided for the other boards are similar:
The sharp spike just to East of the assumed pass mark (based on January grading), says Ofqual, shows that teachers were deliberately “overmarking” assessments to ensure that their little darlings hovering around the C/D borderline got over that line. This assertion has been translated into teachers “cheating” in the popular press, or “massaging marks” in the more restrained version offered up by Chris Cook at the FT (who also uses this graph as the starting point for his analysis).
Unfortunately for Ofqual, the graph shows nothing of the sort, because there is a perfectly valid alterative explanation for the spike East of C: very good teaching.
Thus, as I noted in my comment on Chris Cook’s piece:
The reader [of Chris's piece] may be left with the impression that teachers in England did actually cheat (or “massage marks”). There is simply no evidence for this, and there is an obvious counter-explanation for the rapid rise to the East of the C line in the graph. That is that teachers are getting very good at using relatively new tracking systems to identify before the controllee assessments where each ‘borderline’ pupil needs to get to in order to get the C (or B, or whatever) and then works hard – using 1:1 TA resources etc – to identify what is needed to get them over that line. This is not .’massaging figures'; it’s massaging CA performance.
I know that’s what happens in the school where I’m English link governor – perfectly honest and actually very commendable, though, as you suggest, all part of a crazy system.
In fact, this is acknowledged) in Ofqual report (para 6.12):
In many schools the prediction process is supported by data analysis which is updated frequently. In a typical school marks from student class work and mock exams in Years 10 and 11 were fed into the tracking system every six weeks, and senior management met every two weeks to discuss them. When students were not making enough progress to achieve their target outcomes, interventions were arranged. This process of targeting teaching and learning support to secure target grades has in many schools been successful in previous years, which added to schools’ surprise when this year’s results were not as predicted. Teachers commonly said that they were used to their predictions being “spot-on”.
Yet, despite the acceptance that such targeted interventions have been “successful in previous years”, they are then totally ingnored as a possible explanation for students’ performance “spiking” just after the point where teachers thought they’d gain a C.
Ofqual seeks to back up this overmarking assertion with two other key pieces of data.
First, it compares the ‘East of C’ spike referred to above a similar spike in graphed data from the Year 1 phonics test first used in the summer of 2012:
The “pass” mark of 32 was made available to teachers before they administered the check. The graph shows how teacher scoring was affected by knowledge of the threshold. The graph…shows how many pupils were given each score: fewer than 10,000 were given a score of 31 compared with over 40,000 being given a score of 32 (paras. 6.73-6.74).
If this “spiking” happens even in such “low-stakes assessment”, says Ofqual, then it’s proof that teachers pre-warned about grade boundaries will always overmark to ensure pass rates are higher. This is, again, nonsense. A perfectly valid alternative explanation for the spiking in the phonics assessment case is that they are indeed “low stakes assessments”, seen as bureaucratic nonsense imposed by the government and at worst (as Michael Rosen has argued powerfully) simply invalid as tests of children’s reading ability. In such circumstances, the urge to simply add a mark or two and move on to the real job of teaching must surely have been tempting – an expression of professionalism in the face of DfE unprofessionalism, indeed – and it really tells us nothing about how secondary school teachers operate in very similar corcumstances.
The second set of data used by Ofqual to corroborate its key “teachers overmarking at the root of all our problems” claim comes in the form of sample data from AQA (the biggest exam board for English) showing how teachers marking differed from moderators marks within the well-established 6% “tolerance” (within which limits schools’ marking will be accepted). The two key tables are below:
As regards the data, it’s important to see it in the context of an important note in the Ofqual report’s supporting information (Appendix 2, p.115):
[T]he tolerance limit is normally no higher than 6 per cent of the total raw mark for the unit/component, rounded to the next whole number above (for example, 4.1 and 4.8 are both rounded to 5).
Now, anyone with a basic knowledge of maths knows that this is not the way we normally round; normally if it’s above 0.5, we go up, and down if it’s below. This is not to say the exam boards agreed to do the rounding back in 2000 is incorrect, as the intention was probably around adding an extra bit of ‘rigour’ into the system rather than using the data for later analysis. Nevertheless, using rounding in this way for the core raw data on which the analyisis is built has significant repercussions. This is most easily shown by readjusting the data on the assumption that half the mean scores in the graphs above should have been in the column to the right (a proxy given the lack of raw data in the report, but one which probably underestimates the real change given the shape of the assumed distribution curve).
If you do this exercise for the top graph, you get a very different result from the one shows. For percentage variances in the way they are normally understood, we suddenly find a much smaller skewing towards ‘overmarking’, with 20% of schools actually undermarking, and 70% of schools marking lower, equal to or at only 1% above the moderator (rising to 86% up 2% above, and 96% up to 3% above).
Standing back and looking at this again, you get a quite different picture; nearly all schools mark within 3% of the moderator, even though the tolerance level – established in the first place because of the inherent subjectivity of marking subjects like this – is twice that. That’s actually quite impressive, and teachers should be congratulated, not condemned.
Then there’s the question of who’s getting the marking ‘wrong’. There is an assumption within the report that if teacher and moderator marking is out of kilter, then it is the teacher who is wrong. The report is careful not to blame teachers personally, focusing instead on the pressures they come under, but pressures operate both ways. There is no consideration at all in the report of potential pressure on moderators to ‘undermark’, even though we know perfectly well that exam boards themselves are under pressure to become seen as ‘hard markers’, or lose out in the coming tenders for single exam boards for each subject. It is at least arguable that the pressure on moderators to undermark might be as great or greater than any pressure on teachers to overmark. This isn’t to say that no teachers at all knowingly overmark – it would be as foolish to assert that as it would be to assert that most moderators undermark – but to take only one side on the potential pressures to do either is not acceptable.
Ultimately, this is a cleverly worded whitewash of a report (and it is clever). All the talk of poor practice in Controlled Assessments, for example (which I won’t cover here for relative brevity’s sake) is little more than a smokescreen, and ignores the fact that the legal action now being taken against Ofqual relates not to a Controlled assessment, but specifically to AQA ‘s ENG1F’s, which saw a 10% rise on the C/D grading boundary between January and June; this has a written paper, not a Controlled Assessment (see p.120 of the Ofqual report).
Perhaps most important of all – and the biggest weakness – is that the Ofqual report fails to address in a satisfactory way the key question of whether ‘comparable outcomes’ are an acceptable mechanism for running the whole exam system. As Chris Cook has also shown, Ofqual have largely ignored the possibility that this process, which effectively limits the number of pupils who can achieve each grade, might be unfair because it has failed to take account of real improvements in learning and teaching in schools over the last few years, even though they acknowledge that it is an important variable. Yet in this report, Ofqual simply rejects any notion that they might have some responsibility in this area:
There are also suggestions that this approach does not recognise genuine improvements in national performance in a subject. That is not the case. If exam boards had evidence that the level of performance was at odds with the statistical predictions (either because performance was better or worse than expected) we would expect them to be able to provide evidence for us to consider. In the time we have been using the comparable outcomes approach, there have been some examples of this – for example in AS level World Development and A level Critical Thinking.
And that’s it! Two example of changes in two relatively obscure AS/A levels, and they feel their job is done. No sense of how or why exam boards, beset by the kind of pressures to downgrade that I’ve referred to above might be even vaguely interested in upsetting the GCSE apple cart by acknowledging that children might be better taught than they were a few years ago. Does Ofqual really expect the exam boards to be pro-active? Of course they don’t, but it gets Ofqual off the hook.
Frankly, this is a disgraceful abdication of responsibility, and coming as it does at the very end of the report, it acts as a handy summary of what the reports really about – blaming everyone else for what’s gone wrong.
And of course, behind the Ofqual screen of supposed independence, sits Gove, smiling at the latest success in his masterplan.
The Lancashire Evening Telegraph reports (i.e. copies and pastes a press release) :
A NEW organisation to improve health and social services in Lancashire has been unveiled.
Lancashire County Council has joined forces with Parkwood Healthcare to form a new health watchdog called HealthWatch Lancashire.
Parkwood specialises in providing staff, including nurses, care assistants and project workers, to the NHS, private and voluntary organisations.
From April 2013, the new organisation will replace the current Lancashire Local Involvement Network (LINk) as an independent watchdog, listening to local people’s concerns and ensuring the best services for them.
In dryer terms, Parkwood Healthcare has won the contract from the County Council to run Lancashire Healthwatch (see No.5 in May 2012 Cabinet minutes), pursuant to the Health and Social Care Act 2012.
Clause 183, para 2.2 of that Act requires the following in respect of such a contract:
The arrangements must be made with a body corporate which—
(a) is a social enterprise, and
(b) satisfies such criteria as may be prescribed by regulations made by the Secretary of State
This makes the award of the contract look very odd. I have checked out Parkwood Healthcare on the Companies House site and it is a Private Company Limited by Shares. As such, it is surely outwith the normal definition of a social enterprise.
So have the County Council acted illegally in awarding the Healthwatch contract to Parkwood Healthcare?
Well, maybe, or maybe not. The Health and Social Care Act, courtesy of a late amendment in the Lords (unchallenged by any member of any party), provides a definition of what itmeans by ‘social enterprise’ (Clause 183 para 7):
For the purposes of this section, a body is a social enterprise if—
(a) a person might reasonably consider that it acts for the benefit of the community in England, and
(b) it satisfies such criteria as may be prescribed by regulations made by the Secretary of State.
Now, I’m a pretty good at ‘reasoning’, even if I say so myself, but I don’t consider that Parkwood Healthcare ‘acts for the benefit of the community in England’, precisely because the organisation’s legal status is not one normally associated with social enterpise.
Further, we don’t know what criteria may be prescribed in the secondary regulations, because those regulations are still a matter for consultation; indeed those consultations appear to have a particular focus on what ‘social enterprise’ is to be taken to mean (see Issue 1 in these slides).
So in summary, we have a (Conservative) County Council apparently offering a ‘social enterprise-only’ contract to what is clearly a private firm, but which might just arguably be considered a social enterprise under Andrew Lansley’s new regulations. Except that they haven’t been issued yet.
Further, the contract has been awarded to a Lancashire-registered firm which, at least judging by the website section on the nursing agency part of its business, may have a financial interest in delivering some of the services that it is now being contracted to scrutinise*.
At the very least, I think Lancashire County Council needs to be asked a few questions about this**, including whether it has made provision in the contract with Parkwood Healthcare for its termination/withdrawal, in the event that the secondary legislation makes such a contract unlawful.
* We should be clear that this is not entirely new. According to its accounts, Parkwood Healthcare already has contracts to “act as the host for voluntary organisations to meet and influence service provision” in Lewisham, Harrow and Greenwich, while also offering nursing agency services in the London area.
These contracts come under the previous government’s Local Involvement Networks (LINk) legislation, but the difference is that in these cases their ‘hosting’ services have been subject to a degree of accountability from those members that make up the Local Involvement Network itself (cf. the Lancashire LINk board structure, for example). Under the new Healthwatch provisions there appear to be no such safeguards, with LINks simply abolished in favour of Local Healthwatch arrangements.
** I should stress, not least so as to avoid any risk of legal action, that I am in no way suggesting that Parkwood Healthcare has acted improperly in tendering for the Lancashire Healthwatch contract. It is the Council’s actions that I question.