It's déjà vu, again

It was déjà vu all over again. A short spell of traditional winter cold weather and a winter bug in December were enough to trigger an old-fashioned beds crisis, with hospitals up and down the country resorting to "black alerts" - diverting emergency patients to other hospitals for lack of beds.

It all seemed like a straightforward blast from the past until new Labour's contribution to the situation was revealed by an unguarded response from the press office at St George's hospital.

The giant teaching hospital in south-west London had closed its doors to emergencies and passed them on to busy units at Kingston or Mayday because - wait for it - managers feared breaching government targets for waiting times in A&E.

Just imagine the logical conclusion to this if more than one trust in an area closed its doors to emergencies on the same basis.

Whatever happened to the idea of working in partnership and a duty to co-operate, as set out in new Labour's first NHS white paper 11 years ago?

Back in October, I warned in this column of the consequences of the very sharp reduction in hospital bed numbers over the last two years following more than a decade in which numbers had remained almost unchanged.

There has been a 7 per cent cut in acute beds across England and an 11 per cent drop in London.

I pointed out then that "health bosses and ministers, who now have almost 17,000 fewer acute beds available than when Thatcher was in office, appear to be gambling heavily on the effects of global warming to get us through what has often been a pressurised a winter period."

That gamble appears to have already gone badly wrong. Even before hospitals were hit by the winter vomiting norovirus and a big increase in emergency referrals for cold-weather bronchial problems, they were stretched to capacity and hemmed in by targets to reduce waiting times to a maximum of 18 weeks from the end of 2008.

GP referrals and 999 ambulance calls are again sharply on the rise and the problem has been further compounded by the closure of almost 40 per cent of elderly care beds in London's hospitals since 2002.

So, expect health ministers to be anxiously tapping their barometers in the next couple of months and fearing that, with the prospect of another squeeze to meet Alistair Darling's quest for spending cuts, an even deeper crisis could take shape next winter in the run-up to the last possible date for a general election.

A clueless David Cameron, who is sitting in the wings planning even bigger cuts in public spending if he gets in, is hoping for precisely this scenario to restore his dented electoral hopes.

Primary care trusts face a squeeze

PRIMARY care trusts hold the NHS purse strings. They are currently facing a new round of deficits as the number of people referred for hospital treatment rises rapidly.

At the same time, Alistair Darling wants to scoop £5 billion from public-service budgets in 2010-11 to help in his mission to bail out the banks. The NHS seems set to bear the brunt of the cuts, losing up to £2.5 billion.

A starting point is the Department of Health decision to cap spending to ensure that at least £1 billion of the reported £1.8 billion surplus remains in the kitty.

Primary care trusts will be allowed to spend just £800 million of the cash that has been accumulated in reserves over the next two years.

Bill Moyes, the chairman of the body that monitors foundation trusts, has warned that the gap between the NHS needs for cash and actual allocations could grow to a massive £13 billion by 2013 unless NHS trusts and primary care trusts are able to more than treble the current levels of productivity improvement.

Moyes pointed out that the traditional way of dealing with cash problems, lengthening waiting lists, would no longer be possible if the government implements its proposal for an NHS constitution with a right to treatment within 18 weeks of referral.

The funding formula brought in to channel out cash to the private sector, the so-called "payment by results" system, means that, when patients are treated as emergencies, primary care trusts are obliged to pay up regardless of their plans and intentions.

And GPs, who may have been expected to treat rising numbers of patients in their own homes, are referring far more patients to hospital this winter than a year ago and ambulance call-outs have also increased sharply.

The result is that many primary care trusts which had been forecast to break even or generate a surplus are facing deficits and seeking big cutbacks in the final three months of the financial year.

In London, these pressures run alongside a plan hatched up by the strategic health authority to pay off all the capital's trusts' estimated £575 million debts.

It wants to use the £300 million of surplus cash at SHA level and impose a further levy on primary care trusts for the next two years.

The idea of clearing the debts is a good one in principle, but many London hospital trusts are inherently unstable financially and a condition of the debt clearance scheme is that they deliver a plan to break even year by year.

This raises the issue of a number of highly controversial cuts and closures that have been put on the back burner for the last two years, including the closure of acute services in Bexley's Queen Mary's hospital and also the busy King George's hospital in Ilford, which recently closed its doors to A&E cases as every available bed was full.

To make matters worse, some primary care trusts covering the most deprived areas in England face a new funding formula that will transform them from "underfunded" to "overfunded" overnight, despite the many and serious health problems faced by their population.

Heart of Birmingham Primary Care Trust, along with London's City & Hackney and Hammersmith & Fulham, are among the biggest losers under the new formula. Although each of them receives an increase this year and next, they could face serious problems from 2010, when the increase in NHS funding is expected to drop to 1 per cent or even less in real terms.

Real joint effort saves orthopaedic centre

AS WE face a 2009 in which closures and campaigning are back on the agenda, let's celebrate a major success of campaigners in south-west London.

The new NHS London document A Local Hospital Model For London praises the South West London Elective Orthopaedic Centre, based at Epsom hospital, describing it as a model for other units.

"This is the largest such centre in western Europe," says NHS London.

Its report tells us that the centre, which replaces over 4,000 joints a year, now:

Delivers a surplus for the four trusts

Has had no MRSA infections and has had a 0.1 per cent infection rate overall for a full year

Achieves the 18-week target

Has a low average length of stay for hip and knee replacements

Achieves theatre use of around 95 per cent

Has received no complaints in a full year.

"Given the success of this model, it is recommended that further work should be undertaken to assess the extent to which this can be replicated, the advantages this would bring and what the wider implications would be."

Good. So it's just as well that London Health Emergency, UNISON and local campaigners stepped in at an Epsom-St Helier Trust board meeting three years ago to prevent the orthopaedic centre being flogged off to a US company.

Campaigning, coupled with close attention to what local trusts and primary care trusts are doing, can win some victories and save services which prove to be vital for the NHS.

On the other hand, despair and inaction leave primary care trusts and strategic health authorities to close and privatise anything that they want.

Make it a good 2009 - get active with Keep Our NHS Public and others to defend our NHS before the credit crunch takes another bite out of services that we really can't do without.

Elderly set to fall foul of government budget cuts

AS the financial strings tighten on the primary care trusts, it is a safe bet that the services most under threat will be those usually regarded as soft targets - mental health and care of older people.

Most vulnerable of all are services for the elderly mentally ill, which have been systematically starved of cash even during the years of most generous funding increases and which languish outside the kind of press and media coverage that can put managers on the spot.

The Alzheimer's Society pressed ministers again in December to publish their delayed dementia strategy, which was promised for the autumn but still has not materialised.

The UK is currently in the bottom third of Europe for dementia care, with half a million people with dementia living in England alone.

One in three people aged over 65 will die with dementia, yet, in many cases, sufferers wind up effectively paying huge fees for their own care in private nursing homes or relying upon the unpaid support of family and other carers as social services raise their eligibility criteria to exclude ever larger numbers of vulnerable people.

John Lister is information director of London Health Emergency.