As politicians and medical bodies wrangle over the health and social care bill, those on the front line face the growing fallout
Robert Brady is painfully aware of his own limitations. His right arm is just about strong enough to lift a pint of beer in the pub, but too weak to carry bags of shopping home from the supermarket. Muscle wasting in his right hand, arm and shoulder mean pain, weakness and frustration. A drastic loss of strength in his right arm and dexterity in both hands have damaged his quality of life.
It is two years since an NHS surgeon told the retired design engineer he was a priority and put him on a waiting list for a cervical spinal operation to decompress the constricted nerve roots that are causing his problems.
"But nothing very much has happened since then," says Brady, 71, at his home in west London. Under the NHS constitution he should have been treated within 18 weeks. It's now 105 weeks, with still no date set for the surgery that he hopes will finally bring him relief. Drugs he takes to cope mean he is easily irritated, slow to respond in conversation and lacking memory.
Four dates he has been given for the operation have all been cancelled. On two occasions a more urgent patient took priority so no bed was available.
He complained to Imperial College Healthcare NHS Trust, which runs Charing Cross hospital where he is due to have the surgery, about the way his "deteriorating medical condition is being ignored" and the "careless and non-professional" behaviour, including a failure to respond to his letters. Mark Davies, the trust's chief executive, finally acknowledged last month that it had let Brady down and apologised for causing him distress.
The fact that growing numbers of patients have been waiting longer than they should – for treatment, in A&E or for a diagnostic test – during the coalition's time in power is one of the many issues facing Andrew Lansley, the health secretary.
At the last count almost 250,000 patients in England had been waiting more than 18 weeks, including 100,000 who had to wait at least a year and 20,000 who had been waiting for more than a year.
Critics claim Lansley has created a problem for himself – and the government – by refusing to accept that targets had helped deliver timely care to patients. Lengthening waiting times led the prime minister to overrule his health secretary in the summer and publicly declare that the coalition would stick to Labour's targets.
But waiting times are only one part of the coalition's gathering troubles over the NHS. With the health and social care bill marooned in parliament for 12 months – it was a year ago on Thursday that it was tabled before MPs – there are signs of government panic over a health service too busy reorganising itself, while trying to save £20bn, to focus on patient care.
The Guardian has established that since the end of December the government has found £750m in payments to patch up the NHS. Some £300m is to be used for capital spending; another £150m for social care so that elderly patients can be discharged from hospital; and another £100m to help GPs through the winter, traditionally a busy time for doctors.
"There's no doubt Downing Street is concerned about access to care suffering because of financial pressures and that is why we are seeing money being spent in a hurry," said Chris Ham of the King's Fund, who points out that £200m has been secretly set aside to bring down waiting times.
Lansley's health service is a radical departure from the idea of a state-run, publicly-financed medical care system. Instead the coalition's health service will allow hospitals to get 50% of their income from private patients. It will allow patients a choice of provider, permitting private firms to offer services to NHS patients.
The news that the City's rating agencies are being considered to rate hospital finances is one example of how far the coalition is willing to see a market health economy evolve.
Ministers have refused to release their own assessment of the risks to the health service from the reforms, despite an order from the information commissioner to do so. In a letter from the health minister Lord Howe to Labour's Lady Thornton, the government said an appeal on that decision would only be heard in mid-April and any hearing would take "two weeks". This effectively means any ministerial admission about the bill's consequences will not be released until after it is law.
The British Medical Association, Royal College of Nursing (RCN) and Academy of Medical Royal Colleges, which represents doctors in all the medical specialities, have written to Lansley urging immediate publication of the risk register to enable proper discussion of the bill before it receives parliamentary approval.
Even with the bill stuck in parliament, the NHS is being changed on the ground – which Labour has argued is unconstitutional. The planned devolution of power to family doctors is already happening, with more than 253 clinical commissioning groups (CCGs) formed to purchase care on behalf of patients. Eventually £60bn of NHS buying power will be in GPs' hands.
This signals a shift in patient-doctor relationships. Last week it emerged that obese patients in Hertfordshire are being asked to lose weight before they can be considered for routine surgery. The regime, implemented by the Herts Valleys Clinical Commissioning Group, which covers 50 practices, is thought to be the first in the country. Thousands of patients awaiting procedures such as gall bladder surgery, tonsil removal or hernia treatment will be affected. Smokers will be told to seek help in kicking the habit or face being refused operations.
Critics who fear the bill is paving the way for the privatisation of the NHS point to the fact that, from April, eight areas of community and mental health services will be opened up to competition for the first time. The NHS will lose its monopoly on treating back and neck pain, feet problems and leg ulcers, providing wheelchairs for disabled children and "talking therapies" to tackle mental health problems. PCTs will have to let private firms, voluntary groups or charities, not just the NHS, bid for contracts.
Lansley lauds the new policy of "any qualified provider" (AQP) as an overdue extension of patient choice that will drive up standards. Some charities, such as Mind and Whizzkidz, agree.
But others believe the move heralds a fragmentation that will lead to patients receiving poorer care. Phil Gray, chief executive of the Chartered Society of Physiotherapists, three-quarters of whose members work in the NHS, says that AQP "is already proving to be a disaster for patient care". He points to a slew of complaints from patients that have followed the introduction of an AQP-style variety of providers of musculoskeletal services in a few parts of England.
In Nottinghamshire, for instance, there are now 14 different providers of NHS-funded physiotherapy services where there used to be just one. The inherent difficulty in knowing which of the 14 is the best makes a mockery of patient choice, says Gray.
The whirl of changes in the health service has prompted ongoing criticism from medical and NHS organisations and sparked acute fears for the service's future. On the NHS frontline, doctors and managers have told the Guardian that the transition between the existing NHS and its radically different future is characterised by "upheaval, distraction and confusion".
Such has been the resentment about the "cuts and chaos", that the medical unions are now calling for the bill to be dropped. The BMA's opposition was joined on Wednesday by a call from the RCN for the health secretary to "drop the bill".
It was the RCN's vote of no confidence in the health secretary at its last conference that signalled the depth of professional disquiet. The college's own rolling count of posts disappearing reveals that almost 2,000 jobs went in the last two months.
The structural changes mean it is not just posts that are going, but clinicians being diverted from frontline work. Many GPs are having to spend time away from their surgeries in meetings about the creation of CCGs. Thousands of experienced NHS staff have been made redundant as 150 PCTs and 10 strategic health authorities have been merged ahead of their abolition next year.
Some doctors say PCTs have lost so many staff that they can no longer properly oversee healthcare in their locality, including in key areas such as child protection and patient safety, or maintain the same range of health services. In Surrey, Dr John Doyle, chair of the local medical committee to which most doctors belong, says: "The PCT here preparing for its own demise has caused problems because there are so few staff left. The staff who are left are so stretched that GP practices aren't getting the help that they used to get."
Lansley argues that he will save money by cutting NHS managers – their numbers have risen 28% in the last 13 years, while NHS turnover has doubled in real terms. John McIvor, chair of NHS Lincolnshire, admits it has been "a rollercoaster of a ride".
"We have had to keep staff focused on to delivering improved patient healthcare as opposed to where the next job is. I have been through five reorganisations. Most last nine months. This won't be finished after two years. It's been easily the most difficult."
A spokesman for the Department of Health said: "The health and social care bill will both safeguard the future of our NHS, and move us closer to a health service that puts patients at the heart of everything it does. It ensures that future generations can rely, as previous ones have, on an NHS that is always there, always improving and always free at the point of use.
"The principles of our modernisation plans – patient power, clinical leadership, a focus on results – have always been at the core of the bill, principles which are widely accepted, as reported by the independent NHS Future Forum." The Guardian
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