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Volume 46 Number 22, October 1, 2016 ARCHIVE HOME JBCENTRE SUBSCRIBE

The Conduct of Politics and the Fight for Empowerment

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The Conduct of Politics and the Fight for Empowerment

For Your Information:
A Legal Battle for a Safer Contract and Sustainable NHS

The Battle for the Future Direction of the NHS:
Massive Cuts to Acute Hospital Services Threatened by Sustainability & Transformation Plans
BMJ Blog on the Privatisation of the NHS
NHS Sustainability and Transformation Plans

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The Conduct of Politics and the Fight for Empowerment

The way that politics is being conducted by those who cherish the cartel-style parties is nothing short of hooliganism. The disgrace is that it is being conducted in the name of democracy. It reflects the neo-liberal way of doing things, which is to issue ultimatums and resort to personal attacks, slanders and untruths when the blackmail does not work.

The resort to dictate has become so ingrained with the Westminster cartel parties for which the neo-liberal agenda is the last word in historical development that the slightest challenge to this dictate results in apoplexy. It can be seen, for example, in the way that the Health Secretary has refused to compromise over the universally despised Junior Doctors' contract. In challenging this dictate in court, Junior Doctors have elicited the incoherent and irrational response from the government's lawyers that statements made in Parliament by Jeremy Hunt should not be regarded as his position. At least the Junior Doctors can say that their "imposed" contract is not now being imposed. And the fight continues.


Jeremy Corbyn on the picket lines
during the 1984/5 miners' strike

The hooliganism has been seen within the Labour Party in the failed "remove Corbyn at all costs" behaviour. Those serious in this behaviour seem to have taken their lead from the millionaire warmonger Tony Blair, or at least his New Labour neo-liberal ideology and politics. These attacks on Corbyn, the principles he upholds, and the social movements which he represents, have been relentless. In reality it represents a sharp struggle between what is pro-social and what is anti-social.

However, this struggle is taking place in the context of the complete crisis of the political system and the old way of doing things. The ruling elites have been very happy to see the escalation of dog-fights in the people's and workers' movements. It accords with their method of electoral coups as a permanent feature of life. It makes individuals the issue and when a programme has popular support raises doubts about leadership qualities and tries to undermine stands of principle. This is what the working class and people despise. They reject the gutter politics which treats the people with contempt, pours scorn on building the social movements, and aims to keep the people in a state of disempowerment.


The "new politics" that Jeremy Corbyn affirms that upholds and encourages participation in political life is only just beginning to attempt to come into being. Its outlines are blurred and perhaps illusions exist about the possibilities of its development. But, for sure, what is needed among the people and progressive forces is a break with the old politics which still has influence in the workers' and people's movements. A change is needed not just in policies but in outlook and in the direction the ruling elite is taking society.

There are big concerns in these movements. The Labour Party's slogan under Jeremy Corbyn of "shaping the future" is not so wide of the mark in summing them up. How to shape the future? Those in the leadership of the social movements are striving to break through the blocks to the resistance struggles and change the direction of the economy, social programmes and society as a whole. They know that the conscious participation of the working class and people is crucial. It is also the case that as well as developing the pro-social programme of the working class, which is to increase investment in social programmes, as well as stopping syphoning wealth in the direction of the rich, and thereby developing a pro-social direction for the economy, the movements will come up against those that are intent on upholding monopoly right and implant the old way of thinking and old way of doing things within these movements.

The important thing is for the social movements not to be reconciled to this state of affairs, to keep challenging, and to keep affirming that there is something new, and summing up and learning from their experience. The guideline is for the working class and people to keep the initiative in their own hands, as far as possible, and to take a stand that it is defence of their rights and the rights of all which count. It is up to the people themselves to oppose the trend of depressing the level of political debate and action to the lowest. This will indeed be done by participating in shaping the future, preparing to take control of the future of society. It is a call of the times that the working class and people be engaged in working out the programme for the alternative, an alternative which includes democratic renewal so that the dictate and hooliganism of the cartel-party system is consigned to history.

Together Let Us Chart a New Path!
Let's Work for Empowerment and to Take Control of the Future!

Link to Political Forum on the Future of Society

Article Index



For Your Information

A Legal Battle for a Safer Contract and Sustainable NHS

Justice for Health, September 29, 2016

Justice for Health was set up by NHS staff and powered by crowdfunding to contest the legalities of contract imposition on junior doctors.

It is now established, beyond doubt, that the Secretary of State (SoS) for Health, Jeremy Hunt, is not imposing the disputed contract on junior doctors and that employers of junior doctors are not legally compelled to use it.

Throughout the year we have seen the SoS repeatedly declare imposition of the new contract on junior doctors. Through the process of litigation in the High Court we finally have clarity on his decision-making and legal powers.

Mr Hunt's last minute legal acrobatics have saved him from losing the case but bring no comfort to the thousands affected by his actions in the last year.

He did not previously clarify his position when faced with thousands of cancelled operations, a devastated workforce or a health service in chaos, but instead, only when his actions faced High Court scrutiny.

The case: our three grounds

1) Did the SoS have power to impose the contract?
During the proceedings the defence satisfied the judge that the SoS was not imposing a contract on junior doctors, and merely approving a recommendation that all Trusts adopt a new model contract. The judge was satisfied that the employers understood the SoS' language and powers.

2) Was the SoS unclear about his decision-making and in communicating?
The judge accepted that the SoS language was ambiguous prior to the court hearing, and "in fact lead the junior doctors to conclude that contrary to the reality, the Secretary of State intended to 'impose' the new contract thereby excluding altogether any daylight for negotiation either with the SoS or the employers".

This was only clarified at the last moment in court.

3) Did the SoS made an irrational decision?
The judge noted that it would be very difficult to rule the SoS was irrational to follow the government's own evidence relating to weekend care, staffing and risk. He stated that the SoS had additional reasons which led to initiating contract reforms and that these reasons were rational. Although we disagree with this, it is not unexpected - "irrationality" has an extremely high legal threshold for proof.

Note: Originally we submitted a fourth ground: a challenge against Clause 22 in the February contract which would have allowed for unilateral variation of the terms and conditions, by the employers at any time. Justice for Health was successful in this point and the clause was removed from subsequent contract offers.

The Judgment

The Judgment begins by dismissing claims from the SoS that the case had "no merit", and emphasises that the grounds presented were "serious and properly arguable" and an issue of "wider public importance".

It was made clear that Jeremy Hunt is not imposing a contract on junior doctors, instead merely "recommending" it to NHS employers:

"One significant consequence of this litigation therefore has been that the Secretary of State has, properly and reasonably, taken the opportunity to put his position beyond doubt. Without granting declarations I can nonetheless, formally, record the position of the Secretary of State as articulated in these proceedings. First, the Secretary of State does not purport to exercise any statutory power that he may have to compel employers within the NHS to introduce the proposed terms and conditions. Second, he acknowledges, therefore, that in principle individual employers are free to negotiate different terms with employees…"

Despite warnings from his own civil servants, and being aware that his language was causing confusion, the SoS continued to be unclear over the past year.

"...the Minister was warned that the expressions 'imposed' and 'imposition" had given rise to difficulties. Paragraph [4] of the briefing stated as follows:

"4. It is noted that the press has again today referred to the contract potentially being 'imposed' by you. As you know, references to 'imposition' have been deployed to assert 'wrongly' that you are not aware of your legal powers. To avoid further complaints of this sort, we suggest that it is best when addressing this issue to spell out that the new contract will be introduced by you working together with NHS employers."

The SoS only provided clarity at the last moment, despite previous requests from doctors, politicians and the Justice for Health legal team. This has allowed him to avoid a legal ruling against him.

"Shortly afterwards and essentially in the course of these expedited proceedings the Secretary of State has formally provided elaboration and clarification of his decision"

His lawyers argued that junior doctors' interpretation of parliamentary statements made by the SoS were unimportant and irrelevant. They claimed only the employers (as decision makers) interpretation should be considered. It was distressing for junior doctors and supporters in court to hear the argument presented in this way. The judge has made clear that this was not an acceptable argument, and that junior doctors and those affected by the SoS decision are legally entitled to clarity.

"In the course of argument counsel for the Secretary of State argued that the addressees of the decision were essentially the employers since it was they who had the responsibility for taking decisions on employment matters at the local level and that was what the decision was really about. However, Mr Sheldon QC, for the Minister did (somewhat reluctantly) acknowledge that employees were also affected. In my view employees were manifestly a critical category of addressee of the decision."

The judge has dismissed the defence's claim that junior doctors were fully aware the SoS was not imposing a contract, an argument that was met by audible gasps from those who were present in the High Court.

"I accept the evidence of the junior doctors that they were in genuine doubt as to whether or not there was any negotiating daylight left following the Minister's statement and, further, construed the Statement as entailing the Secretary of State compelling introduction or implementation of the contract and thereby eradicating further negotiating options."

The judge has pointed out that now there is clarity the SoS is not imposing a contract, there remains an opportunity for further negotiations. Employers have in principle the freedom to choose whether or not to adopt Hunt's recommended contract.

"[SoS] now accepts that there is in principle negotiating daylight which exists. But I have accepted the Secretary of State's analysis by looking, with the obvious benefit of hindsight, at the full range of relevant documents, the most important of which would not have been available to the junior doctors prior to this litigation."

Our final message:

We have worked very hard to get this case to court and we are thankful to have had the opportunity to hold Mr Hunt to account. The judicial review proceedings were necessary to gain clarity in the law and force Mr Hunt to answer for his conduct.

We hope it sets a precedent for better ministerial conduct and deters the SoS from making statements about imposition on other NHS staff groups.

After a short break, Justice for Health may explore further legal challenges and campaigns we could help take forward on behalf of NHS staff and patients.

Whilst we hoped for the top result, we have met our initial goal to extract clarity from the SoS and will now move on. We resolve to help the BMA to exert legal pressure in any way possible to combat the exploitation of NHS staff and annihilation of good quality patient care we have witnessed at the hands of this Health Secretary.

For further information, see www.justiceforhealth.co.uk

See also an interview with Amar Mashru, Justice for Health, following the announcement that the High Court had found in favour of the Secretary of State for Health, Jeremy Hunt, in the judicial review. The interviewer was Tony O'Sullivan, co-chair of Keep Our NHS Public: www.youtube.com/watch?v=SVD0OPy3CFg

Article Index



The Battle for the Future Direction of the NHS

Massive Cuts to Acute Hospital Services Threatened by Sustainability & Transformation Plans


Jeremy Corbyn supporting the Save South Tyneside Hospital Campaign at the 80th Anniversary Celebrations of the Jarrow March. Speaking there he said that "health care is a right not a privilege".

Over recent weeks there has been a growing impact on health care services from the 44 Sustainability & Transformation Plans (STPs) that are being drawn up in secret at the behest of NHS England and the government. These plans, which are to be finalised in October, are designed to massively cut NHS services, downgrading hospital acute services and A&Es throughout England over a five-year period. They are being prepared by "footprints" of CCGs (Clinical Commissioning Groups) that have no status in any Act of Parliament and are not elected bodies.

According to a statement of Health Campaigns Togetheri following their conference in Birmingham on September 17: "Drafts of all 44 plans were submitted in July: but as of now only six relatively complete drafts have been published - for North West London, Hampshire and Isle of Wight, Dorset, the Black Country, Wider Devon and Shropshire." These plans all centre on achieving drastic "efficiency" savings, to stave off a deliberately contrived "gap" of £22-30 billion by 2020. The statement continues: "The North West London draft makes clear that most of the core savings are to come from closing hospitals, centralising services, squeezing more 'productivity' from already hard-pressed hospital staff, redundancies and dumping more unpaid tasks onto GPs and primary care services, as well as onto family carers."

The statement also points out: "The proposed new models of 'out of hospital care' will also open the door to selling off NHS estate to fund the NHS 'deficit', as well as further privatisation - contracting out for US-style 'accountable care partnerships' and for 'Multispecialty Community Providers'." The statement also goes on to note the current disastrous fragmentation, underfunding and widespread privatisation of social care, making a comprehensive integrated service impossible.

Two Examples

In the North West, the STP is behind a new attempt under the government's ironically named "Success Regime" to close consultant led maternity services at West Cumberland Hospital (WCH) in Whitehaven forcing women with birth complications to travel to the Cumberland Infirmary some 40 miles away. The midwives from west Cumbria published an open letterii in August warning, "We cannot believe that you would remove consultant cover from WCH. Surely the lives of pregnant ladies are worth much more than a cost cutting exercise? We are told that these cuts are for safety reasons. That we know is not true. We also know that: - Mothers will die - Babies will die - Babies will be brain damaged - Families will be traumatised" if consultant-led maternity care is removed from the West Cumberland Hospital.

In the North East, South Tyneside Hospital is being subject to the downgrading of all its acute services in a new "alliance" with City Hospitals Sunderland - a move that threatens the downgrading and loss of its stroke, maternity and other acute services and the downgrading of its A&E to a minor injuries "Urgent Care Centre" as a result of a secret STP that plans a cut of 15-20% of the budgets of both hospitals over five years. Already, the new Chief Executive of this alliance from Sunderland within ten days of coming into his post immediately said action has be taken "as quickly as possible" to move South Tyneside stroke services "temporarily" to Sunderland prior to any consultation. The chair of Save South Tyneside Hospital Campaign, Roger Nettleship, pointed out: "We are getting no guarantees from either the hospital leaders, or the Clinical Commissioners that we will have consultant led stroke, maternity, or a fully operating A&E by the end of next year. We are calling on the people of South Tyneside to campaign against this whole direction to downgrade our hospital and we will be holding our first demonstration in South Shields next month on October 22 in South Shields to defend our hospital and our NHS."

There are campaigns uniting the people in many areas of of the country which are being organised regardless of political views of the people involved and keeping the initiative in the people's own hands to safeguard the future of their NHS and chart a new path against this continued direction of wrecking the NHS. Access to health care is a right of everyone in a modern society, and this right must be guaranteed for all. Resources must be ensured for the training of doctors and consultants required for all acute and community services. Locally accessible district hospitals with a wide range of properly funded acute and emergency services must be retained. Public right should prevail and the duty of government to provide a comprehensive health service across England to all communities must be restored.

i http://www.healthcampaignstogether.com/pdf/Joint%20statement%20FINAL.pdf
ii http://www.itv.com/news/border/2016-08-10/midwives-warn-mothers-will-die-if-maternity-care-is-downgraded/

Article Index



The Battle for the Future Direction of the NHS

BMJ Blog on the Privatisation of the NHS

Alex Scott-Samuel, a senior public health academic and joint chair of the Politics of Health Group, blogged in the BMJi website that the government's present programme of privatisation of the NHS set in motion by the Health and Social Care Act 2012 was given a further boost in July in two policy papers, the Strengthening Financial Performance and Accountability in 2016-17ii and the NHS Improvement Business Plan 2016/17iii. He says that the government aimed at a "quiet publication" by issuing them during the Parliamentary recess but that these are "the latest set of instructions on the implementation of NHS chief executive Simon Stevens' Five Year Forward View (5YFV)".

The papers are clearly aimed at bolstering the plan to railroad NHS Chief Executives, NHS Trust boards and CCGs to sign up to the Sustainability & Transformation Plans to facilitate the privatisation of the NHS by the end of this Parliament in 2020. The hallmark of the 5YFV has been the creation of a universal set of NHS trust financial deficits based on arbitrarily imposed cash limits over five years, limits which cut the budgets of the NHS so that present services can no longer be maintained without wholesale closure of hospitals, hospital beds, A&Es, and community services and the massive outsourcing of the non-clinical services to the private sector as "back office". In other words with the government body Monitor enforcing compliance NHS England is now using those "deficits" to legitimise impossibly tight controls on hospital trusts, clinical commissioning groups (CCGs), and other NHS agencies to ensure they conform to central proposals for cuts and mergers between NHS institutions.

Alex Scott-Samuel points out that the plan states that providers will be required "to transform services in line with the 5YFV and this will include making use of new care models and innovative organisational forms." A priority for 2016/17 is "to facilitate independent sector providers to form NHS partnerships".

He says we are told: "We intend to bring together the most promising potential areas for formal collaboration between NHS Improvement, providers, independent sector partners, NHS England, and other key stakeholders into a new work programme. The key elements of this programme in the first instance will examine the opportunities in the areas of:

- mainstreaming clinical capacity for elective, outpatient, and diagnostic care;

- joint ventures and/or outsourcing of new, novel, or restructured clinical services;

- joint ventures and novel financing for facilities and/or technology;

- independent sector management models to support capability and leadership challenges."

This is with the aim of promoting mergers, cuts, and closures in the publicly provided NHS and introducing community based "integrated packages of care", which are readily amenable to private sector provision and insurance funding - as occurs in the US Accountable Care Organizations on which this particular "new model of care" is based. In other words, he is saying that the direction is forcing the bigger Trusts to not just outsource their "back office" services to private companies but to form partnerships with the private sector for this "new model of care".

Alex Scott-Samuel concludes that "it is no coincidence that the House of Lords is currently calling for evidence to be submitted to its new select committee on the long term sustainability of the NHS. This inquiry, supported by government ministers, is likely to make recommendations that will legitimise the aims of Stevens' five year plan, including the 'inevitability' of top-ups, co-payments, charges, and of the short term personal health budgets and longer term health insurance system that would be required to fund them. This toxic combination of an increasingly insurance based and increasingly privately provided health service will signal the final dismantling of what was once our National Health Service in England - a horrific and destructive act, which we now know to have been first proposed by Prime Minister Theresa May's predecessor Margaret Thatcher in 1982."

i Alex Scott-Samuel: Tory plans for NHS privatisation released during parliamentary recess
http://blogs.bmj.com/bmj/2016/08/05/tory-plans-for-nhs-privatisation-released-during-parliamentary-recess/
ii https://improvement.nhs.uk/uploads/documents/Strengthening_financial_performance_and_accountability_in_2016-17_-_Final_2.pdf
iii https://improvement.nhs.uk/uploads/documents/Final_Bus_Plan_16-17_13july.pdf

Article Index



The Battle for the Future Direction of the NHS

NHS Sustainability and Transformation Plans

What Was Said

On September 14, the Opposition debate in the House of Commons took place on the NHS Sustainability and Transformation Plans (STPs). The motion was moved by Diane Abbott, Shadow Secretary of State for Health. We reproduce extracts from the debate, edited for continuity.

Diane Abbott: I beg to move,

That this House notes with concern that NHS Sustainability and Transformation Plans are expected to lead to significant cuts or changes to frontline services;

believes that the process agreed by the Government in December 2015 lacks transparency and the timeline announced by NHS England is insufficient to finalise such a major restructure of the NHS;

further believes that the timetable does not allow for adequate public or Parliamentary engagement in the formulation of the plans;

and calls on the Government to publish the Plans and to provide an adequate consultation period for the public and practitioners to respond.

I am glad to open this debate on the NHS sustainability and transformation plans. As the whole House knows, the NHS has a special place in the affections of our constituents. No other public service engages with us all when we are at our most vulnerable - in birth, death and illness - and the public and NHS staff are increasingly aware that the NHS is under severe financial pressure, a matter I will return to.

In that context of financial pressure and concern about the availability of services, the sustainability and transformation plans are arousing concern. They sound anodyne and managerial, and there is undoubtedly a case for bringing health and social care stakeholders together to improve planning and co-ordination. But the concern is that, in reality, the plans will be used to force through cuts and close hospitals, will make it harder for patients to access face-to-face consultations with their GPs, and, above all, will open the door to more privatisation. It tells the public how little the Secretary of State cares about their concerns that he is not in the Chamber to listen or respond to this debate. We know that recently he has missed all seven recent meetings of the NHS board. The public are entitled to ask how much he cares about their very real concerns.

One of the most alarming aspects of the STPs is their secrecy. England has been divided into 44 regional footprints, and it is worth noting that they are called footprints to distract from the fact that they are ad hoc regional structures - they are the exact same regional structures that the Tory health Bill was supposed to sweep away. Because they are ad hoc and non-statutory, they are wholly unaccountable. In the world of the STPs, the public have no right to know.

Initially, the STPs were discouraged from publishing their draft plans, freedom of information requests were met with blank replies, and enquirers were told that no minutes of STP board meetings existed. We are therefore bound to ask: if the plans are really in the interests of patients and the public, why has everyone been so anxious to ensure that patients and the public know as little as possible?

GP leaders in Birmingham said that it would appear that plans by the STP to transform general practice, and to transform massive amounts of secondary care work into general practice, are already far advanced. Only at this late stage have they been shared with GP provider representatives.

So when the STPs talk about efficiency, they actually mean cuts. Increasingly at the heart of these STPs are asset sales of land or buildings to cover deficits. No wonder the leader of Hammersmith and Fulham Council, Stephen Cowan, has said of his local STPs that

"this is about closing hospitals and getting capital receipts".

He went on:

"It's a cynical rehash of earlier plans. It's about the breaking up and the selling off of the NHS."

The Health Select Committee's recent report on the impact of the 2015 spending review stated:

"At present the Sustainability and Transformation Fund is being used largely to 'sustain'

in the form of plugging provider deficits rather than in transforming the system at scale and pace. If the financial situation of trusts is not resolved or, worse, deteriorates further, it is likely that the overwhelming majority of the Fund will continue to be used to correct short-term problems rather than to support long-term solutions".

Other aspects of the STPs that relate to cutting expenditure involve a combination of factors, including the use of new technology such as apps and Skype, patients taking more responsibility for their own health, "new pathways" for elderly care, increased reliance on volunteers and the downgrading of treatment by skills, responsibilities and pay bands. It seems to me that while some of these proposals might have some merit in themselves, it is delusional to imagine that they will deal with the financial black hole in the NHS. There is no evidence that among the patient population as a whole, increased use of apps, Skype and telemedicine can produce the efficiencies required while beds, units, departments and hospitals are being closed.

I remind Members, many of whom speak to their constituents in their advice surgeries on a weekly basis, that the truth about speaking to people face to face is that it is often towards the end of the conversation that people will come out with what really concerns them. My concern about the increased use of Skype is that many patients will not get the familiarity and comfortableness with their interlocutors to enable them to say at the end of the Skype session what it is that they are concerned about.

The STPs talk a great deal about increasing preventative medicine. That would indeed have the effect of lowering demand for acute NHS care, but it would also require a very substantial investment in public health programmes - and this Government have just cut public health funding. The elderly, the poor and patients for whom English is not their first language are the least likely to use these apps, telemedicine and Skype. It is inappropriate and unrealistic to assume that elderly patients who, I remind Members, are the biggest users of acute care and the fastest-growing demographic, will want to use Skype for any sensitive matter. "New pathways" for the elderly is sufficiently vague as an idea to raise alarm bells, given the projected rise in demand for geriatric services and continuing cuts in social care funding.

It was the NHS England director of STPs, Michael McDonnell, who said that they

"offer private sector and third sector organisations an enormous amount of opportunity".

We know that PricewaterhouseCoopers has been heavily involved in the formulation of a large number of these plans, and we know that - as was mentioned earlier - GE Healthcare Finnamore, which was taken over by General Electric in the United States, has been heavily involved in the formulation of plans in the south-west and possibly more widely. The strong suspicion is that a combination of cuts, the reorganisation of services on a geographical basis, and the growth of hospital "chains" will facilitate greater privatisation of the NHS.

Heidi Alexander, Labour, Lewisham East:

I am grateful for the opportunity to speak in this debate. Sustainability and transformation plans - what are they, should the public be concerned, and are the plans good, bad or a mixture of both? As we have heard, over the last eight months or so STPs have been drawn up in 44 areas in England by a range of people involved in the running of the NHS and local government. As far as I can work out, they have come about because NHS England could see that in the chaos following the previous Government's Health and Social Care Act 2012, there was no obvious body responsible for thinking about how best to organise NHS services at a regional and sub-regional level, so NHS staff and local government officials were tasked with assessing the health and care needs of their local populations, considering the quality and adequacy of the provision to meet those needs, and developing ideas about how those needs might be better met within available resources.

So far, so good, we might say, but there are three big problems. First, the current financial pressures on the NHS mean that the plans are likely to be all about sustainability, not transformation. Secondly, this is a standardised process to define and drive change, so we run the risk of good proposals being lumped in with bad ones, and of some plans simply focusing on the achievable, as opposed to the necessary and the most desirable. Thirdly, it is an inescapable fact that these plans are being developed when there is huge public cynicism about the motives of a Tory Government when it comes to change in the NHS. If the Government want to deliver change, the debate with the public needs to start in the right place - not behind closed doors, and not using jargon that no one understands. It needs to be focused on patients and their families, not on accountants and their spreadsheets.

I think most people understand that the NHS cannot be preserved in aspic. They understand that compared with the 1950s, we now use the NHS in a very different way. At the moment, they simply see an NHS under enormous pressure. They are waiting longer for an ambulance, to see a GP, to be treated in A&E and for operations. They see staff who are stressed out and who are on the streets in protest. When Ministers and NHS leaders talk about sustainability and transformation, the public are therefore dubious. For sustainability, they read cuts, and in some cases they will be right - it will mean cutting staff, closing services and restricting access to treatment. No matter good the plan, how thorough the analysis or how innovative the solution, we cannot escape the basic problem of inadequate funding for the NHS and social care.

As a country, we have a growing and ageing population. The reality is that in the last 10 years, the number of people living beyond the age of 80 has increased by half a million, and the NHS and social care are buckling under the strain. Although we should never give up on trying to organise the NHS in the most efficient and effective way possible, we have a choice. Do we want to cut services to match the funding available, or do we want to pay more to ensure that our grandparents and our mums and dads get the sort of care that we would want for them? If the NHS is to provide decent care for older people we need not only to fund social care adequately, but to find better ways of organising services to keep people out of hospital for as long as possible.

That leads me to the next problem. STPs are being used as a catch-all process to bring about change in the NHS, but many run the risk of focusing on the wrong things. They are being used as a vehicle to do different things in different places, and although some may lead to better treatment and better outcomes, the danger is that there will be knee-jerk, blanket opposition to everything. Some proposals will inevitably be controversial - the closure or downgrading of an A&E or maternity department will never be easy - but, in other cases, the plans may end up focusing on something that is not the burning issue.

Let me take my local area as example. The STP for south-east London proposes two orthopaedic elective care centres. The sites for them have yet to be decided, and the STP plan has yet to be signed off by NHS England. On the face of it, there is little wrong with the proposal to create centres of excellence so that all hip and knee replacements are done in one of two places. The problem is that when the front page of a national newspaper talks about the "secret" STP plans under which A&Es will close, my constituents fear the worst. "We've been here before," they will say. They will smell a rat, even where one might not exist.

My constituents ask me these questions. What happens if Lewisham is not the site of the new centre, its elective work is shifted elsewhere and the hospital then struggles to staff the emergency department? Is orthopaedic care really the burning issue in south-east London? What about the queues of ambulances outside the Queen Elizabeth hospital? What about the homeless young man who pitches up in A&E because he has nowhere to sleep and there is no support for him in the community?

Where will the money come from physically to redesign the NHS buildings that such a care centre would entail? With £l billion taken out of capital budgets and switched to revenue last year, it seems fanciful to think that there will money lying around for such projects. The NHS is on its knees. Everyone knows that hospitals ended up £2.5 billion in deficit last year. We have all seen the reports of A&Es closing overnight because they have not got the staff. We all know that GPs are run ragged, that ambulance crews are stressed out and that nurses are demoralised, and that is before mentioning the junior doctors.

This is the main problem for the Government: if you do not fund the NHS adequately and if you do not staff it properly, do not be surprised when the public do not trust your so-called improvement plans. There is deep public cynicism when it comes to anything this Government wants to do to the NHS. People believe Ministers are trying to privatise it. They believe services are contracted out to the private sector to save money, not to improve quality, and in many cases they are right. The problem is not STPs as such, but the context in which they are being developed - inadequate funding, an inability to make the case for change, a workforce crisis that is leading to overnight closure of services and, as a result of all of these, a deep public mistrust of the Government's intentions.

Andrew Slaughter, Labour, Hammersmith:

I hope that I am in a position to assist some of the Members who feel that they are in the dark or confused about what is in their STPs. That is not because my own sub-region, north-west London, is one of the two, I think, that have officially published their schemes - I fear that, like most NHS documents, it is written in a style and language that make it difficult for the ordinary public to understand. Rather, it is because, for north-west London, this process has not mushroomed overnight, as has been the case with STPs generally, but has been developed over four years. In the wonderful Orwellian language that is used, we have had something called "Shaping a Healthier Future" since the middle of 2012, and that has simply morphed into the STP, so I can perhaps give a little insight in the few moments that I have.

What did "Shaping a Healthier Future" mean? It meant the loss of 500 acute beds. It meant that of around nine major emergency hospitals two would, effectively, be downsized to primary care, and four A&Es would lose all their consultant services - and that, as far as I am aware, is still the plan. What has become clear with the transformation into STPs is that this is very much about money. The original language four years ago was that unless we implemented these cuts to acute services, we would "go bankrupt". When that language did not go down very well - not surprisingly - with the 2 million people affected in west London, the language changed, and it was all about clinical care.

I am pleased that at least the honesty is now back in the system, and the proposals are now very much about money. One sees why when my own hospital trust - a very important, prestigious trust called Imperial, which runs three major hospitals - is over £50 million in deficit this year alone. The CCGs are flatlining on funding. The importance of that is that the only possible justification for these major cuts in acute care is that social care, community care and primary care funding will be increased. How that is possible with budgets that are, at best, standing still, I really do not know.

The other interesting factor is the delays that have occurred over this time. We had this proposal in the middle of 2012 and a slight revision in February 2013 - and then silence. I have lost count of the number of times I have been promised that a full business case will be published. I act as the unofficial shop steward for the 11 Labour MPs in the sub-region, and I summoned them all to a meeting and said, "You're going to get the business plan this month." It was going to be next Tuesday, and we were all coming in in the recess to look at it, but, guess what, it has been put off until at least after the new year.

Moreover, the plan is now thought to be so unwieldy and so difficult to achieve that it has been split in two. My own hospital - Charing Cross - was due to lose 90% of its acute beds and its consultant emergency services, and we simply do not know when the proposals will now be published, but it has already been taken outside of the STP process. In other words, it is beyond the five-year horizon, and nothing will happen until 2022. Now, in one way, of course, I am delighted that the demolition balls are not going into Charing Cross for that period, but in the meantime the lack of support the hospital is getting worries me greatly.

These STPs are a Trojan horse for cuts. They are about cuts in acute services before there are compensatory services. For that reason, Members should be extremely concerned and worried about them, and I am happy to share my pain and knowledge on the subject if any Members wish to hear about them.

Emma Lewell-Buck, Labour, South Shields:

We have all become accustomed to the Conservative party's disdain for our NHS since the shambles of the top-down reorganisation that began in 2012. Now we have the stealth introduction of sustainability and transformation plans - secret plans that would bring yet more unjustifiable and drastic reforms to cash-starved hospitals. Instead of being given the funding they so desperately need, hospitals are being asked to make £22 billion of efficiencies to compensate for this Government's total mismanagement of our NHS. The audacity of making hospitals themselves pay the price for that by threatening them with closure or the reduction of acute services is the final act of treachery in a tragic and deliberate play to decimate our NHS.

South Shields is part of the footprint area of Northumberland, Tyne and Wear, an arbitrarily created boundary. By 2021, the health and social care system in that footprint area is projected to be £960 million short of the funds it needs to balance its books while maintaining the same level of care for patients. Make no mistake: these plans are about cuts. They are nothing to do with transforming our NHS for the better. The NHS has been set an impossible task by the Government; the endgame is to see it in private hands.

The Government have said that the initial STP submissions to NHS England are

"for local use, and there are no plans to publish them centrally" - a nice touch to put the onus once on to our hospitals again, so that the Government themselves do not have to deal with the flak.

I was born in South Tyneside hospital. I am the local MP for the area, and I have not seen a single plan. Not even the governors at my local hospital have, let alone the people of Shields, whose vital acute and emergency services could be devastated by these changes.

I am told that the timetable for implementing these unseen plans begins this autumn, yet the first we will see of them in my area is at the end of this month - that is, in the autumn. I am extremely alarmed at the lack of accountability and transparency with which the plans are being pushed through. There is simply no time at all for consultation. I make a plea to all NHS leaders not to be complicit but to stand up for their hospitals and the communities that they serve. The Government have no mandate for such a radical reconfiguration of our NHS, one that could involve the closure of accident and emergency and acute services up and down the country.

Last week, the Prime Minister called in NHS leaders to order them to stop any hospital mergers or closures that risk causing local protests. There is already a protest in my constituency.

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