Opinion: #KillTheBill – but not for a reason you may be aware of…

This weekend saw the LibDems argue both for and against the Health and Social Care Bill. It may be a cliché, but whilst I’m in the #KillTheBill camp, I am still proud of our democratic system that allows votes on both sides of the argument to be counted (interestingly, I had to explain to supporters of the bill that those of us arguing against don’t want NO bill, just not THIS bill – for some reason they seemed surprised at that).

I spoke to both Paul Burstow and Judith Jolly about some of the concerns I have, and I pay tribute to them for the open, frank and attentive way they discussed the issues, it was a positive experience in terms of the discussion level.

I’d like to highlight one issue I’d ask you to seriously consider if you currently support the bill.

Most of you know that tariffs are going to be set for services. I accept this as a good thing for the reason that it does at least stop under-cutting by private firms to win an operation over a more expensive NHS option or other private provider, part of the “protection” to choose between quality rather than choice that is argued by Shirley Williams’ team. There are, however, 3 issues with this:

    Discussing with Dr Charles West, he listed 20 different types of hip operation (based on the fact complications and other contra-indications may cause issues with a seemingly basic operation) – however there will not be more than one tariff; clearly the maths fails here.

    The tariffs will not be set BEFORE the Bill is due to be enacted. So, the Bill asks to base services on a tariff for all operations, but then the tariff list won’t be available – this surely means that all operations from the point the Bill is enacted, to the point when the tariffs are finally made available will have to be postponed, with tens of thousands of people waiting in pre-op wards until a price is decided; clearly the logic fails here.

    The 3rd option is something I’m frankly so disturbed over, it needed its own paragraph: tariffs are also going to be set for mental health services. I tried to explain to Paul and Judith that you simply cannot offer a price-tag on a mental health provision. Firstly, it opens the door to BigPharm companies to prescribe, via GPs who follow this method of treatment, even more anti-depressants that they currently do, as a tariff has to be set on a measurable thing and the cost and number of tablets is an easy way to do it.

Secondly, Paul explained that “experts” are going to set the prices, and thus everything will be ok, as the experts will know what prices to set. Leaving aside the obvious flaw in that experts don’t actually exist (how much time, experience and knowledge in a field must one have to become an expert?),how on earth can price £X be given to treat someone with, say, schizophrenia, Post-Traumatic Stress Disorder or, the biggest of all, clinical depression?

There simply is no figure one can apply to “a” treatment that can take 5 days, 15 years, or the whole life-span of the patient; the time, people-resources and treatments offered to each patient is completely unique. This applies to many physical operations; however it applies to ALL mental health treatments. If one list can be drawn up that has a fixed price for every patient with mental health issues, and this is proven to always be right (such as predicting the level and length of treatment needed) I state clearly now that I’ll join the Monster-Raving Loony Party and fight for Prime Ministers to be legally required to always be dressed as Elvis. Clearly that will never take place, as the challenge can NOT be met.

I therefore argue to #KillTheBill on literally this ONE point alone, or, at the very least, I publicly plead with Shirley to contact me about this to discuss further and hope we can come to a conclusion which removes this requirement.

Mental Health provision is already so badly mis-handled in some cases, the notion of then getting the all-knowing, all-seeing omnipotent commissioning groups to use one price for each patient in this field is enough to scare me away from the bill in its entirety.

Lee Dargue is a member of the Telford & Wrekin Liberal Democrats and a Vice-Chair of the West Midlands Regional Party.

* Lee has long campaigned on mental health in and out of the Lib Dems, he is the PPC for Birmingham Ladywood and speaks for the Party on Health, in the West Midlands.

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21 Comments

  • jenny barnes 13th Mar '12 - 2:18pm

    But what you get from the NHS now is either a 6 session CBT counselling intervention, or anti-depressants. So it would be pretty easy to set a tariff for that. Oh, you need a lot more of a different kind of counselling? Do you have money?
    The NHS doesn’t work well now, for many people.

  • Excellent article Lee – and I fully endorse the “just not this Bill” message. The NHS is badly in need of reform, not least the acute sector which drives tremendous cost on adult social care. This Bill came from nowhere and should go back there. Then, involving the sector, let’s look at what isn’t working and what we could do better and draw some evidence based solutions of how to address them.

  • I agree with Jenny Barnes with regards to CBT therapy

    The NHS metal health care is shockingly under resourced and underfunded. I am not convinced that the proposed bill is going to do anything to change that or make it better even.

    I received almost 2 years of weekly CBT therapy from the NHS, during this time I felt constantly under pressure that I was taking up resources. My therapy would be extended by 10 weeks at a time, but as we were coming to the end of the sessions, I would be asked how I feel about stopping therapy, how much longer do i think I need therapy.
    It was absolutely awful and I felt pressured into getting well and getting of their books so to speak.

    Eventually, I was told that there was no more that could be done for me, even though i still suffered from severe depression and suicidal tendencies along with self harming.

    My own GP was mortified but confessed that his hands were tied and he could not refer me again “unless” I ended up in hospital again with an overdose, or, I was out in public threatening to harm myself or a risk to others.

    I was appalled that in order to get help I had to become even more of a danger to myself or others.

    It was for that reason alone that I decided to fund my own therapy “Privately” out of my benefits. It is a huge drain on my limited income, however, I am not put under any expectations or pressure and my therapist fully understands my need for continuous support.

    Nothing in the NHS bill convinces me that things would improve with the new bill, I do not believe you can put a £ on anybodies recovery or needs as everybody is different.

  • Matt – “Nothing in the NHS bill convinces me that things would improve with the new bill, I do not believe you can put a £ on anybodies recovery or needs as everybody is different.”

    Correct – in theory.

    However, the NHS does not have, and never has had, limitless funding. Couple that with an ageing population and ever more complex treatments and sophisticated drugs, and you have a situation where the outgoings outstrip the incomings. So … you either have to up the incomings or reduce the outgoings, or make decisions about what will be funded and what won’t be.

    In other words, you ration.

    This is the furstrating debate we never, ever, have in this country, and it is why the NHS is as near to a secular religion as you can get. The myth is that everyone always gets the best and most expensive treatment immediately – and its one I have sympahty with – its what everyone as an individual would want, after all. But the hard reality is that we as a society are not prepared to pay for its implementation.

  • Spot on, Tabman. Finite resources implies rationing – but we have never had the reasoned argument that we need to have on this subject, so we end up with the famous postcode lottery …

    How did Labour avoid grown-up discussion? This is how Polly Toynbee described their approach: ‘The history of Labour’s “reforms” hardly bears repeating; minister after minister reversed direction, created then tore up 10-year plans, dismantled then resurrected a market the party inherited. It invented new primary care groups, remade them into primary care trusts, then merged them again into half the number. It demolished regional health authorities, put in 28 strategic health authorities, then merged them back down to the 10 original regions. And that’s only a thumbnail sketch of the great breathless deckchair shuffle done by Milburn and Reid.’

    Constant ‘reform’, target-setting, and throwing money at the NHS has brought us to where we are now … a good time, perhaps to kill the bill and have some sensible discussion.

  • James Jones 13th Mar '12 - 4:02pm

    The tariffs will not be set BEFORE the Bill is due to be enacted. So, the Bill asks to base services on a tariff for all operations, but then the tariff list won’t be available – this surely means that all operations from the point the Bill is enacted, to the point when the tariffs are finally made available will have to be postponed, with tens of thousands of people waiting in pre-op wards until a price is decided; clearly the logic fails here.

    Lee, you misunderstand how bills, and then Acts, actually get implemented. In the legislation are a number of clauses and subclauses which set out when each bit of the bill will become law. Normally this is left to the Secretary of State (i.e. the Health Secretary), who issues what is known as a commencement order. What will happen, if/when the bill becomes law, is that the tariffs will be designed, and when they are fully ready, then those sections of the Act will be commenced. Until then, the current system will continue to operate. This is absolutely standard practice and means that new organisations get some set-up time before they have to fully carry out their new statutory functions – it does not not all change immediately Royal Assent is given!

    James

  • 1. “Most of you know that tariffs are going to be set for services.”

    And some of us know that they have been for ages:
    http://www.hsj.co.uk/news/finance/new-nhs-tariff-upsets-pct-financial-plans/5002021.article
    http://news.bbc.co.uk/2/hi/health/3461585.stm

    They have been around for a decade or more.

    2. The Lib Dem Huhne Commission at this time pointed us in the direction of diversity in the provision (rather than funding )of services.

    3. Before the last General Election Norman Lamb, as Lib Dem spokesman, made a case for hopitals being forced to match lowest cost providers.

    4. Sid and Tabman are spot on.

  • Richard Dean 13th Mar '12 - 7:06pm

    Interesting to see people here praising the US healthcare system. Not a car crash, more like limo reserved for the rich! Do you actually have an altenative for the UK, other than an unsustainable and unrealistic bottomless pit of money?

  • jenny barnes 13th Mar '12 - 7:43pm

    Lee & Matt. Yes. CBT can be useful for some people in some situations, but often it’s just symptomatic relief. Like antidepressants really. Matt – you were lucky to get 2 years of therapy – but I suspect you have needs which are just not met by CBT. 2 years with little or no improvement indicates that. Sorry, I’m going off topic.
    The NICE approach of evaluating treatment by QALYs per £ is the nearest we have to a debate about rationing. I wonder how that’s going to work under the new regime.

  • Andrew Suffield 13th Mar '12 - 8:11pm

    this surely means that all operations from the point the Bill is enacted, to the point when the tariffs are finally made available will have to be postponed,

    Somebody has already discussed why legislation doesn’t work this way, so let me fill in the gap with what’s actually going to happen instead:

    Until a new system is ready to take over in a given area, the current NHS will continue in exactly the same way it currently does.

    There simply is no figure one can apply to “a” treatment that can take 5 days, 15 years, or the whole life-span of the patient; the time, people-resources and treatments offered to each patient is completely unique.

    You are misunderstanding the use of the word “treatment” here. The tariff would be set for something like “each one hour session with a therapist”, not “all psychiatric resources a person encounters during their lifetime”.

    There are many things wrong with the NHS currently, especially in relation to how mental health treatment is funded, but the bits of the bill that you’re talking about simply don’t mean the things you suggest.

  • Richard Dean 13th Mar '12 - 8:55pm

    @Andrew Suffield. Has this kind of information not been published somewhere officially? The absence of information is doing nothing to help persuade people to support the bill. It is also very surprising given the importance of the NHS in our culture. Can anything be done to remedy this?

  • Andrew Suffield 14th Mar '12 - 2:01am

    Has this kind of information not been published somewhere officially?

    Heavens no. The debate has been entirely focussed on making up nonsense about the bill, so nobody’s had any time for anything so tedious as information.

  • @Andrew Suffield

    “Heavens no. The debate has been entirely focussed on making up nonsense about the bill, so nobody’s had any time for anything so tedious as information.”

    If this is the case, where did the information come from to support your previous post?

    “You are misunderstanding the use of the word “treatment” here. The tariff would be set for something like “each one hour session with a therapist”, not “all psychiatric resources a person encounters during their lifetime”.

    There are many things wrong with the NHS currently, especially in relation to how mental health treatment is funded, but the bits of the bill that you’re talking about simply don’t mean the things you suggest.”

  • John Carlisle 14th Mar '12 - 9:08am

    Forget all the discussion about the policy implementation and how bills come into fruition. The reason the bill is so dangerous is that it will be ruinously expensive to implement – and then it will not work anyway. Already we are seeing the supine leadership of many Trusts closing wards and laying of staff, and the damage to patient care and to the budget of GPs setting up the CCGs. This is only the beginning.
    The next step will be the employment of consultants from the big five plus to help speed up implementation, which will be their foot in the door and the tax-payers’ hands deeper in their pockets.
    That, at this time, is why we need to kill this bill; which may just prove to be the removal of the cornerstone of our party.

  • Andrew Suffield 14th Mar '12 - 9:16am

    If this is the case, where did the information come from to support your previous post?

    Tariffs have been in use in the NHS for years. That’s how they work.

  • Nigel Quinton 14th Mar '12 - 8:06pm

    @tabman – whilst you are correct that there will continue to be tremendous upward pressure on health spending we must not lose sight of the fact that the UK spends considerably less on healthcare than many other countries.

    I cannot find the latest reports, but the 2007 comparison produced by the UN on per capita spending on health had the following top 16: ($/capita)

    United States 6,096
    Luxembourg 5,178
    Norway 4,080
    Switzerland 4,011
    Austria 3,418
    Iceland 3,294
    Canada 3,173
    Germany 3,171
    Belgium 3,133
    Australia 3,123
    Netherlands 3,092
    France 3,040
    Sweden 2,828
    Denmark 2,780
    Ireland 2,618
    United Kingdom 2,560

    Now we may not be able to afford to increase spending now, but it is not unreasonable to increase spending if our economy and government deficit improves.

  • Nigel Quinton 14th Mar '12 - 8:20pm

    I agree with several of the criticisms of the original post – sorry Lee – but the key point is that made by Martin Tod. Fragmentation and a reliance on National tariffs are not going to help the NHS and run counter to experience elsewhere. The issue with this bill is the difficulty and COST of its implementation, and (IMO) its likely failure to meet its stated objective of improved accountability. I am unconvinced that the HWB and Scrutiny structures will be sufficiently democratic, and am aghast that one of the better proposals in the original Bill – the plans for Healthwatch – have been totally watered down to the point where there will be no resource for patient advocacy.

    I am as disappointed as Andrew Suffield with the quality of some of the debate but this applies to both sides – much as I respect Paul Burstow’s intentions, his engagement with the party and with the public on this Bill has been poor. (I made this point to him at the last conference, and he acknowledged it could be better, but I have not observed much improvement since)

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