John Lister (Health Emergency)
The phony war is over. With Andrew Lansley's Bill now on the statute book, the gloves are off, and the extended standstill in the process of cuts in pursuit of the £20 billion "efficiency" target has come to an end.
But don't be fooled: this is no cock-up. It is all planned to happen.
One after another, desperate hospital trusts are revealing glimpses of their real financial situation. And accident and emergency units are at the top of their list as they start to close and cut - not because much can be saved by simply closing them - but as a crucial first step to dismantling and closing whole hospitals.
With A&E goes maternity, paediatrics, ITU, High Dependency Units and Coronary Care. With maternity goes women's care. With the loss of trauma goes orthopaedics. Emergency surgery is pronounced "unsafe" or "unsustainable" and removed.
Each element takes a range of supporting services with it, until the hospital is allowed to wither away: and each cutback also makes it harder to recruit medical staff and qualified nurses, opening up arguments that further cuts are required because staffing levels are "unsafe".
To cap it all, trendy arguments are wheeled out by the King's Fund, McKinsey and other hired hands suggesting that new "settings" can deliver services more efficiently and effectively than hospitals: the only snag is that these "settings" and services exist only on paper, lacking evidence they work, and of course the funds, facilities, staff and any political commitment to make them a reality.
Each A&E closure is dressed up and presented as a "clinical" decision: but we know they're being cynical. Vague promises of services "closer to home" end up with the closure of local hospitals that local people value and depend upon, but nothing to replace them.
The reason we know this is because, alongside A&E units, they're also cutting community services and cutting mental health - and the consultation documents on the closures keep referring to the "cash gap", the level of savings they say they need to make.
The list of cuts is growing longer week by week. In London we know that four A&E units - Ealing, Central Middlesex, Charing Cross and Hammersmith - face the axe in northwest London, St Helier hospital in Southwest London is to be run down, King George's hospital in Ilford, and of course Chase Farm in Enfield.
Across the country there are more: hospitals in Stafford, Rugby, Kidderminster, Redditch, Trafford General in Greater Manchester, Newark, Northallerton and Hartlepool. Among the A&E casualties are some brand new units built with the Private Finance Initiative [PFI]: Central Middlesex cost £62m less than 10 years ago: Bishop Auckland hospital, another PFI, is also to lose its A&E. But also on the hit list are hospitals unlucky enough to have been merged with PFI hospitals, or run by them.
Best known of these is Queen Mary's hospital in Sidcup. It has already been largely dismembered in a futile attempt to balance the books of the South London healthcare trust, which is wrestling with ruinous bills for two hospitals, which cost about £210m to build, have been on the brink of bankruptcy for years, and are now dragging down health services for a million people in southeast London. After paying over £500m, there's another £2 billion still to pay.
Administrators have now been brought in to drive through rapid and drastic cuts, although it's still not clear what could be done to tackle such massive debt. Even if all services closed and all clinical staff were sacked, the Trust would still have a massive PFI bill to pay for 20 years: and no nearby hospitals have any spare capacity to treat the tens of thousands of patients displaced from Bromley, Greenwich and Bexley.
The curse of PFI is also driving cuts in Dewsbury in Yorkshire, which was unlucky enough to be merged into the Mid-Yorkshire hospitals trust, whose a newly completed £320m PFI deal fell immediately and deeply into crisis. Dewsbury could lose its A&E, while Pontefract's brand new urgent care centre has already been scaled back, and the main hospital in Wakefield, short of beds, struggles to cope.
But for managers these cuts are too small, and take too long to meet the massive £20 billion cuts target, which is ridiculously being called the 'Nicholson Challenge', when in reality it should be called the Banker's Bonus, the Lansley Bequest, or the Tax Dodgers' Legacy. The cuts were triggered by the banking crisis, deepened by Lansley as part of his plan to run down public sector provision in health and make room for private sector providers, and continue despite the fact that uncollected tax alone adds up to £120bn a year, six times the £20 billion target for cuts by 2014.
So bosses are looking to cut jobs - and even going beyond the current pay freeze to cut pay, with Trusts in the South West seeking to tear up the national Agenda for Change pay scales and threatening heavy tactics to impose pay cuts, and other bosses looking to downgrade staff to cut wages - in some cases by over £2,000 a year.
Job cuts are also on the way - even as we wait to hear the outcome of the inquiry into Mid-Staffordshire hospitals, where trust managers cut too deeply into nurse and medical staffing - with notoriously lethal results. And many trusts are now making cuts much bigger than the £10m that destabilised Mid Staffs.
While savage cuts undermine local services and the quality of care in those services which survive, the rush for private contracts is hotting up, in a new bonanza for the likes of Virgin Healthcare, Serco and other companies looking to cash in - slicing off attractive portions of NHS funded services, while leaving all the complex, costly and risky tasks to what remains of the public sector.
Virgin has now picked up lucrative contracts in community health care, and primary care, and even sexual health services and child health in Devon. Serco, too, is moving in anything they can get their hands on. That company's conspicuous failure to deliver on its contract to deliver out of hours primary care in Cornwall raises questions not only about Serco (pocketing the difference from chronic under-staffing) but also about completely ineffectual regulation and monitoring of private sector contracts by PCTs now, and by CCGs from next year .
Behind the scenes profitable consultancy firms like McKinsey and Ernst & Young are helping themselves to lavish contracts and lining up to take over a growing share of the work running the new Clinical Commissioning Groups (CCGs) and their £60 billion budgets.
And while NHS budgets are frozen and falling against inflation, with less money each year for each treatment they deliver, NHS Foundation Trusts are also being freed to boost their budgets with private medicine: up to 49% of income can come from private sources .
While the private contracts are awarded behind the scenes, angry people up and down the country are beginning to mobilize to challenge the closures of local services. They may not really understand privatisation in the NHS or anything about Lansley's Bill, but Mr and Mrs Middle England do know and care about the loss of local emergency services and how long it would take them to go to the next hospital across if their local A&E is closed. This offers a basis of common ground for campaigns to link the issues of cuts privatisation and Lansley's Act.
Campaigns are cranking up. Consultations already just beginning on the cuts, and already public opinion is hardening against them. Some ministers with endangered hospitals in their constituencies are running for cover.
Campaigners have to press their local MPs, councillors, community organizations and CCGs to take a firm stand against these cuts.
Take every chance to challenge, block and delay every cut: they are all driven by a cash squeeze the coalition could resolve tomorrow if they collected the tax that's owed from their rich friends. Some are also driven by PFI: and ministers could sort this out as well, but prefer to leave the gravy train running for their friends in the private sector and watch the NHS squirm.
The cuts are deliberate, the crisis consciously created to open up our most popular public service to profiteers. Don't let them get away with it.
It's time to take a stand, reject the specious "clinical" case for cash-driven closures, and fight for our hospitals. Remember once it's gone, it's gone.