The hidden cost of NHS reform

These commercially-driven changes to our health system will be the worst of all worlds.

Last year the NHS paid out nearly £800 million in damages and costs for clinical negligence claims. Although part of an upward trend, it was not an exceptional year. In fact, some £15 billion is held in reserve against current potential liabilities: that is, existing claims or those which are anticipated but where no payment has yet been made. Even in a world inured by the financial crash to the mention of astronomical figures, these are significant sums of money.

We should, therefore, all be interested in the effect that the coalition's radical restructuring of the NHS is likely to have on the incidence of clinical negligence litigation. Thus far, however, the focus has been elsewhere. Unfortunately, both theory and experience say that there is much in these proposals which should concern us.

Whatever the sophistry of its proponents, a scheme in which of the provision of clinical care is outsourced to "any willing provider' can, in reality, mean only one thing: that the potential provider of that care will primarily be judged not on how good that care will be but on how cheaply it will be given. Even leaving aside the additional pressures on costs which apply uniquely to private healthcare organisations (the generation of profit and the payment of dividends to its shareholders), the need to undercut its competitors in the NHS will inevitably impact on their primary item of expenditure: their staff. Fewer doctors and fewer nurses will have to work longer shifts: in other words, the very environment in which mistakes are most likely to happen. Good news for the lawyers: less so for the patients and for the taxpayer who has to foot the bill when a claim is made.

If it were necessary to test that theory against experience, one would need to look no further than the provision of out of hours GP care. Until April 2004, this service was provided in-house by Primary Care Trusts and/or GP practices. Since then, it has been possible for this to be out-sourced to independent commercial providers (a concept which should sound familiar to those examining the current NHS proposals).

In the event, such concern was generated by the succession of adverse events which followed that change that in June 2009 -- and prompted by the tragic death of a patient in February 2008 after he was administered a gross overdose of diamorphine by a locum doctor from Germany -- the Care Quality Commission began an investigation into the provision of out-of-hours primary care services. Its interim statement on this investigation, in turn, prompted the Department of Health to commission its own inquiry. That report, published in June 2010, should have made uncomfortable reading for the evangelical proponents of the Coalition's plans. There is no indication, however, that anyone, from Mr. Lansley down, has ever read it -- or, indeed, seen any of the countless stories in the media about the failures of out of hours care in the years since 2004.

I am a clinical negligence barrister. According to the popular stereotype of the lawyer, I should be willing the Coalition's bill to be passed. I am, however, not only a lawyer: I am a taxpayer and a human being and I have seen too many tragic accidents and appeared at too many inquests not to implore the government to think again.

These proposals are patently driven by commercial imperatives rather than by consideration of patient wellbeing. Even on those narrow terms, and ignoring their human cost, they will not succeed if any money saved on the provision of care is simply spent on compensation for those who suffer as a result.

John Whitting is a QC and member of the Labour Party.

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The tale of Battersea power station shows how affordable housing is lost

Initially, the developers promised 636 affordable homes. Now, they have reduced the number to 386. 

It’s the most predictable trick in the big book of property development. A developer signs an agreement with a local council promising to provide a barely acceptable level of barely affordable housing, then slashes these commitments at the first, second and third signs of trouble. It’s happened all over the country, from Hastings to Cumbria. But it happens most often in London, and most recently of all at Battersea power station, the Thames landmark and long-time London ruin which I wrote about in my 2016 book, Up In Smoke: The Failed Dreams of Battersea Power Station. For decades, the power station was one of London’s most popular buildings but now it represents some of the most depressing aspects of the capital’s attempts at regeneration. Almost in shame, the building itself has started to disappear from view behind a curtain of ugly gold-and-glass apartments aimed squarely at the international rich. The Battersea power station development is costing around £9bn. There will be around 4,200 flats, an office for Apple and a new Tube station. But only 386 of the new flats will be considered affordable

What makes the Battersea power station development worse is the developer’s argument for why there are so few affordable homes, which runs something like this. The bottom is falling out of the luxury homes market because too many are being built, which means developers can no longer afford to build the sort of homes that people actually want. It’s yet another sign of the failure of the housing market to provide what is most needed. But it also highlights the delusion of politicians who still seem to believe that property developers are going to provide the answers to one of the most pressing problems in politics.

A Malaysian consortium acquired the power station in 2012 and initially promised to build 517 affordable units, which then rose to 636. This was pretty meagre, but with four developers having already failed to develop the site, it was enough to satisfy Wandsworth council. By the time I wrote Up In Smoke, this had been reduced back to 565 units – around 15 per cent of the total number of new flats. Now the developers want to build only 386 affordable homes – around 9 per cent of the final residential offering, which includes expensive flats bought by the likes of Sting and Bear Grylls. 

The developers say this is because of escalating costs and the technical challenges of restoring the power station – but it’s also the case that the entire Nine Elms area between Battersea and Vauxhall is experiencing a glut of similar property, which is driving down prices. They want to focus instead on paying for the new Northern Line extension that joins the power station to Kennington. The slashing of affordable housing can be done without need for a new planning application or public consultation by using a “deed of variation”. It also means Mayor Sadiq Khan can’t do much more than write to Wandsworth urging the council to reject the new scheme. There’s little chance of that. Conservative Wandsworth has been committed to a developer-led solution to the power station for three decades and in that time has perfected the art of rolling over, despite several excruciating, and occasionally hilarious, disappointments.

The Battersea power station situation also highlights the sophistry developers will use to excuse any decision. When I interviewed Rob Tincknell, the developer’s chief executive, in 2014, he boasted it was the developer’s commitment to paying for the Northern Line extension (NLE) that was allowing the already limited amount of affordable housing to be built in the first place. Without the NLE, he insisted, they would never be able to build this number of affordable units. “The important point to note is that the NLE project allows the development density in the district of Nine Elms to nearly double,” he said. “Therefore, without the NLE the density at Battersea would be about half and even if there was a higher level of affordable, say 30 per cent, it would be a percentage of a lower figure and therefore the city wouldn’t get any more affordable than they do now.”

Now the argument is reversed. Because the developer has to pay for the transport infrastructure, they can’t afford to build as much affordable housing. Smart hey?

It’s not entirely hopeless. Wandsworth may yet reject the plan, while the developers say they hope to restore the missing 250 units at the end of the build.

But I wouldn’t hold your breath.

This is a version of a blog post which originally appeared here.

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