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As NHS cuts bite, we will soon see the

next eruption of popular anger
Andrew Lansley's disruptive reorganisation will see waiting lists go
up and treatments withdrawn. The blue touchpaper is lit

Polly Toynbee
The Guardian, Saturday 11 December 2010

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Rioting by a few, peaceful protest by many, an attack on the heir to the throne and the
throwing of bricks at Treasury windows, all this makes eye-popping TV news footage.
But plenty more issues over the next year have the same potential to light the blue
touchpaper of public opinion, without necessarily spilling on to the streets.

Political volcanologists watching for eruptions should be turning their seismographs on

the NHS. In his early days, David Cameron saw that the NHS could do the most damage
to Conservatives: he neutralised fears of Tory plans to dismantle it by pledging himself
pink in the face to protect it. He even used his sick son's NHS treatment as proof of his
sincerity. The NHS would get a "real increase" every year, with none of the plague of
disruptions visited on it by previous governments. The sacred text of the coalition
agreement promised: "We will stop the top-down reorganisations of the NHS that have
got in the way of patient care." But now each pledge is broken. John Healey, shadow
health secretary, emerging as a soberly effective and emphatic critic, this week exposed
how new inflation figures show the NHS will suffer a real cut, alongside its most
radically disruptive reorganisation.

Listen to the warning rumblings. This week, at the thinktank the King's Fund, there was
a stunned silence followed by a great ripple of approval as a key NHS executive burst
out in frustration that the service was heading for "a bloody awful train crash". The
chief executive of Ealing primary care trust, now taking over several neighbouring
PCTs, spoke with passionate authority of how all his time is taken up with
reorganisation, "completely clearing out my team and making a whole series of new
appointments … I am not spending a moment thinking about patient care or money".

Many primary care trusts have heavy debts they are expected to pay off fast, before
handing over to GPs to commission all NHS services. No one thinks it possible. PCTs are
sending out letters ordering GPs not to refer patients for anything but urgent surgery. In
public they talk of stopping cosmetic procedures and treatments for tattoo removal – or,
as Zoe Williams reported this week, stopping IVF, causing immense suffering. However,
the cancellations go much further – Surrey, Warwickshire, Lancashire and almost every
other PCT is delaying surgery for hips, knees and even cataracts, sometimes until the
new financial year.

By banning GPs from referring, they avoid falling foul of Labour's NHS rule requiring
treatment within 18 weeks of GP referral. Other delaying wheezes include refusing to
treat smokers until they take a course on giving up (Surrey, £35m overspent) or fat
patients until they lower their body mass index (Portsmouth City). Some stay within 18
weeks by delaying all surgery until 16 weeks – though that catches up with itself.

What happens when PCTs save money? They pass their debts on to hospitals, which

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suddenly find their surgeons have fewer patients to treat and less money coming in. The
only effective cost-saving is through strategic planning – to rationalise services into
specialist hospitals, as with the life-saving stroke treatment re-organisations. But the
government is scrapping strategic health authorities, believing a perfect market will
rationalise itself. That requires a lot of hospitals to go bust – politically impossible since
Cameron joined pre-election hospital protests pledging no closures.

Alarm is widespread, but usually off the record. The Ealing PCT manager was only
echoing the sentiments of the head of the NHS, Sir David Nicholson, who told the
health select committee that the PCTs being abolished were in "meltdown" as the best
managers fled: only "Stalinist" controls could now keep a grip on NHS finances he
warned. The former Tory health secretary, Stephen Dorrell, head of the committee,
gave a taster of what his report next week may say, warning the same meeting that no
health service had ever achieved what is now being squeezed from the NHS, a 4%
annual saving for four years.

Waiting lists are where the NHS bursts out under pressure. Professor John Appleby of
the King's Fund is monitoring them, not trusting the government to keep the figures.
Whitehall departments may stop collecting central data: in the guise of localism,
ministers say it's up to local citizens to hold services to account, with no need for
centralised figures or odious comparisons.

This week health secretary Andrew Lansley ignored every red light to launch 52
pathfinder GP consortia, commissioning services for a quarter of the population. He
claims they will "put patients at the heart of everything the NHS does". That sounds
cosy, as if your local GP will commission for you; but most consortia will be larger and
more remote from patients than the PCTs they replace. One pathfinder is Great West
Commissioning in West London, where GPs have contracted United Health to run its
referrals.

Only a quarter of GPs in surveys express enthusiasm. Dr Clare Gerada, head of the
Royal College of GPs, has been fiercely critical, warning that, if GPs are responsible for
rationing, they will lose people's trust. Patients will eye their doctor's BMW in the drive
and ask if that's why they aren't getting a treatment they need.

The government has put GPs in command: they may be saints as individuals but,
collectively, they have held governments to ransom ever since 1948. They rarely do
anything new without extra pay: look how they bamboozled John Reid and Alan
Milburn into a huge rise. Their tough four-year freeze ends conveniently just as the new
system goes live in April 2013. Already fuming at suggestions of a pension cut and
retirement at 65, expect them to force a goodly screw, pushing the £3bn cost of
Lansley's plan higher. The chair of the Association of Independent Medical Accountants
warns that GPs' pension protests will "make the student demos look tame". Hyperbole,
no doubt.

But look at this cocktail of trouble brewing – an organisational upheaval, significant

numbers of GPs opposed, and an unprecedented real cut in cash when the NHS needs
3% to stand still. Now watch the fast-rising surgical waiting lists. Every local and
national paper will fill up with NHS anecdotes of woe by next year. Labour all but
abolished waiting lists for the first time, but waiting used to top the poll of public
discontent year after year. As with the tuition fees fiasco, this reorganisation at a time of
the harshest funding was an ideological choice. The NHS will provide another crisis of
the government's own making.

guardian.co.uk © Guardian News and Media Limited 2010

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