Situation critical for the NHS

In the topsy-turvy world of today's NHS managers, it seems that it's now cheaper to provide better care than it is to provide inferior care.

That's what health bosses in north-east London have been telling sceptical journalists who ring up to inquire how they are planning to slash £500 million from hospital budgets by 2015, in addition to cutting the budget for primary care, mental health and community services by between £200m and £500m.

"We are not cutting services or standards," says the official statement, loyally reprinted by local hacks in Hackney, Tower Hamlets and points further east.

"And because better care is often more cost-efficient than poor-quality care, we can release funds to spend on better treatment for more people."

It sounds absolutely fantastic - the better your health services become, the more money you save.

So if, like the NHS in England, you are staring down the barrel of a £20bn gap between your likely budget in five years and the likely demand for health care, you had better get out there quickly and start improving things fast.

In fact every aspect of health care by this criterion should be ratcheted up to the very best imaginable to save even more money.

What a fortunate coincidence for these managers and for the clinicians who have rubber-stamped the controversial proposals to downsize or close down hospitals, privatise non-acute services and shift millions of out-patient and minor A&E cases from hospitals into primary care that all of these are now seen as "improving" health care and are expected to save money.

Sadly the sums don't quite add up like that - NHS bosses' own "pre-consultation business case" shows that in north-east London, to have any hope of balancing the books, they need a massive cut in nursing budgets of between 21 per cent and 37 per cent.

They also need to slash spending on doctors by up to 43 per cent, they need to reduce overhead costs by 34 to 42 per cent, increase other productivity by up to 32 per cent and cut spending on drugs by up to 25 per cent.

By most people's reckoning a health service with fewer, more harassed nurses and doctors, fewer support staff, fewer hospitals and fewer beds, coupled with cost-driven restrictions on the prescribing of drugs, is not a better-quality service at all.

In a labour-intensive service such as health care, everyone knows that each squeeze on staffing levels reduces the level of patient care.

The north-east London plans also include pruning upwards of £60m from budgets by "decommissioning services."

In north-west England, strategic health authority bosses have even joked about "world-class decommissioning" - cutting better and bigger than any other country in the world.

But the new mythology is growing. In the Bart's and London Hospitals Trust, which is building a gigantic £1bn, 1,000-bed new hospital complex across the two sites with money put up by banks through the private finance initiative (PFI), managers have become even more fanciful and creative in answering awkward questions.

Asked by the East London Advertiser about plans set out by Health for North East London to close 234 of these beds - before the new building is even completed or opened to the public - a spokesman insisted: "There would be 'almost' the same number of beds as there is now, because they will be used 'more effectively'."

But hang on a minute. If they didn't really need 1,000 beds in the first place, why are they now being so expensively built - at the staggering cost of £1m per bed?

Why did the trust itself negotiate and sign a rigid, legally binding contract to pay for all 1,000 beds in the new building for a minimum of 35 years from completion?

On an index-linked scale of charges, that will cost the NHS a cool £5.2bn by the time the contract is completed. What are these new techniques that mean 770 beds are as good as 1,000?

These managers are not levelling with the public. The picture is too good to be true.

They are trying to lull us - and maybe themselves too - into a completely false sense of security, while the actual plans spell out the need for massive, unprecedented increases in productivity or equivalent cuts in spending.

Changes this big are set to transform the face of health care, wipe well-loved hospitals off the map, throw tens of thousands of health workers on to dole queues and trigger massive public anger.

This is clear from the scale of the cuts that are being contemplated - far, far larger than anything attempted when Margaret Thatcher was in office.

But health bosses don't want to alert the public to what is happening and so don't want to discuss the full magnitude of their own plans.

Hidden scale of the cuts

Health Emergency has been trying to piece together a national breakdown of the coming cuts, trawling through Strategic Health Authority board papers and seeking ways to fill in the many gaps.

With firm published figures for seven of the 10 strategic health authorities, it seems that the likely total is £20bn to be cut, with London planning by far the biggest cutback at £5.1bn - equivalent to £670 for every man woman and child in the capital, compared with an England average of £400.

With just 15 per cent of the English population, London for some reason seems set to shoulder up to 25 per cent of the cutbacks.

Some other piecemeal figures are starting to emerge.

Manchester is to face £1bn in cuts and the West Midlands £2.4bn. NHS South East Coast and NHS Yorkshire and Humberside have admitted that they are working on the basis of the 10 per cent target for reduction in staff set out last summer by management consultants McKinsey's - in a document which ministers were quick to disavow.

Plymouth Hospitals Trust faces a cut of £33m as the south-west seeks to cut spending by £1.35bn.

But if the overview figures are hard to get, any more detailed picture of how NHS bosses expect to save these colossal sums can be even harder to find.

North-east London is the only area so far to have put proposals out to consultation, but even here the real picture can only be found not in the vague and evasive consultation document but in an inconspicuous 192-page document published on December 22 and tucked away quietly on the Health for North East London website.

Meanwhile across much of the rest of London NHS chiefs are sitting in secret session, keeping a paranoid watch on every document, with each draft being counted in and out and hand-delivered to the magic circle of decision-makers for fear of leaks.

The public is denied the information - and the chance to criticise the underlying assumptions behind the proposals.

Every request under the Freedom of Information Act for publication of the McKinsey document used as the basis for NHS London's guidelines has been rebuffed - for almost six months now - on the spurious argument that it might impede discussions. So suspicions cannot be confirmed or answered.

Those suspicions are reinforced and multiplied by duplicitous NHS press officers and managers claiming to journalists that they "do not recognise" figures taken from their own board papers and effectively trying to argue that black is white and improved care comes from spending cuts.

But in the meantime many of us will suspect that little or no cash saving can really be made by switching outpatient and minor injury services from hospitals to "primary care settings" and that plans for bed reductions and huge productivity increases from fewer staff are based on wishful thinking rather than hard evidence.

But the obfuscation and prevarication cannot do more than delay the angry reaction which will erupt when hospital closures and job losses are announced - and this reaction will take place whichever government wins the election in May and takes on the poisoned chalice of health cuts.

There is a real chance that the new government may be forced to retreat from some of the more heavy-handed cuts and closures - but whatever happens, few will want to forgive the health bosses who are still withholding vital information, wilfully misleading the public and building a drama into a future crisis.

John Lister is director of Health Emergency.