A survey by the NHS Confederation shows that 70% of the heads of NHS organisations believe access to care is deteriorating.

Only 7% said significant progress was being made in integrated care, and two-thirds said the lack of progress meant that services were “unsustainable”.

Mike Farrar, NHS Confederation Chief Executive and a champion of integrated care, said the survey results were “very worrying”.

The NHS Confederation, the membership body for NHS commissioners and providers, supported the NHS reforms but has since expressed concern at the impact of austerity policies.

Financial pressure, with the ‘Nicholson challenge’ now known to be an absolute cut in NHS spending, was flagged by 60% of NHS leaders as a “serious” problem and by 83% as one that would worsen in the coming year.

Half of the respondents said waiting times and access to care had deteriorated in the past year, while 70% said they would do so in the next 12 months.

“In the short term the NHS is holding it together,” said Mike Farrar, “But the sticking plasters on the creaking parts of the system will only last so long. We are already seeing the pressures on our A&Es bubbling over.

“Effective long-term change will require NHS leaders, with the support of the public and politicians, to take up the gauntlet and see through some radical changes to the way we deliver care,” he concluded.

The birth of the new, deregulated NHS came only days before the death of the politician whose career made it possible. Pf looks back on the legacy of the Thatcher era for healthcare in the UK.

When Margaret Thatcher died on the 8th April, they were still removing the last shreds of bubble wrap from the new NHS structure. The blueprint of the Health and Social Care Act (2012) is a monument to Thatcherism. It transforms the NHS from a nationally owned, publicly funded healthcare system to one driven by competition and governed by business law – a system designed for rapid, continuous change under the influence of market forces.

The architect of these reforms, Andrew Lansley, is a politician very much in the Thatcher mould: autocratic, forceful, not worried about consensus. His statement that the Government’s ‘listening exercise’ was only necessary because the doctors had to have the reforms explained to them was straight out of the Iron Lady handbook.

In order to assess the impact of Thatcher’s legacy on healthcare, it’s essential to appreciate that NHS market reforms began on her watch. Even the relatively minor step of outsourcing hospital cleaning was casting a shadow over hospital care decades later.

And the fundamental reforms outlined in 1989 – the NHS internal market and the purchaser/provider split – laid the foundations of the market reforms that followed under the governments of Major, Blair, Brown and Cameron. As historian Charles Webster has observed, the 1980s and 1990s saw “continuous revolution” for the NHS.

It’s become a cliché of retrospectives on Thatcher to say that the Iron Lady ‘left the NHS alone’. It’s true that her government had other fish to fry, notably the onslaught on the manufacturing industries and their trade unions that culminated in the miners’ strike.

Thatcher noted in her memoirs that in most respects, the NHS provided “high quality care at reasonably modest unit cost” and commanded public “affection”. She was in no hurry to privatise it – but that did not mean she left it alone.

Iron rations

However, the Thatcher government’s first health policy initiative was one of deliberate inaction. The Black Report into health inequalities, published in 1980 after a failed Conservative attempt to block its publication, noted that health inequalities in the UK were linked to socio-economic factors such as income, housing and conditions of work. The Government rejected the report’s findings and recommendations.

The 1980s were not an easy decade for the NHS. Major developments in drug therapies and surgery increased healthcare expectations and costs, while a massive increase in unemployment accentuated public health needs. The main theme of Thatcher’s health policy was cost control, building on the public spending restraints of the Callaghan government. The phrase ‘death by a thousand cuts’ became endemic in health journalism.

Diabetes patient Richard Grimes recalls the austerity climate of the NHS at that time: “My memories of that clinic were peeling paint on the outside and a filled waiting room on the inside. The most bitter memory was the battle the British Diabetic Association had with the government over disposable needles. I was expected to inject twice a day with re-usable needles. These got blunt quickly, but I was expected to use them for months. As a result I developed scar tissue in my injection sites. Finally the Thatcher government relented and I got sharp needles.”

Two significant policies of the early Thatcher years increased the role of the private sector in healthcare. In 1980, NHS consultants’ contracts were changed to allow all to do private work with no detriment to their NHS income (previously those also doing private work were paid about 18% less). As a result, it became the norm for consultants to divide their time between the public and private sectors.

In 1983, the government legislated to make hospitals put their cleaning services out to competitive tender. This meant that the job of cleaning wards went to the lowest bidder – often to companies that used casual, untrained sta. supplied by job centres. The contrast between the high quality of surgical treatment and the dirtiness of wards became notorious. The level of hospital-acquired infections grew steadily, until in 2005 the Lancet noted that the UK had “one of the highest rates of MRSA in the world”.

Thatcher wanted to introduce more radical changes – such as a shift to an insurance based healthcare model, with ‘health stamps’ for the poor – but in a busy decade, her battles with trade unions and left-wing Labour councils took priority.

The great divide

The third Thatcher term saw a crisis of hospital capacity, provoking a review of the NHS that aimed to address its financial problems through competition. The 1989 White Paper Working for Patients gave rise to the NHS and Community Care Act (1990), engineered by the ambitious Health Secretary Kenneth Clarke within the Major government. It introduced two important reform policies.

The NHS internal market separated the functions of purchasers (health authorities) and providers (hospitals and other organisations). The latter competed for service contracts within a business framework. Hospitals became trusts: independent, self-managed bodies. By 1997 almost all NHS hospitals were trusts. One effect of this change was that administration costs doubled from 6% to 12% of the NHS budget.

GP fundholding was an attempt to develop a similar framework for primary care. Family doctors were encouraged to join a scheme whereby they received budgets to buy non-emergency care services from NHS providers, instead of relying on those purchased in bulk by their health authority.

Fundholding doctors were often able to obtain services more quickly than those outside the scheme. By 1997 about 50% of GPs were fundholders. The scheme cooled the professional relationship between primary and secondary care, and many patients saw it as a ‘two-tier’ healthcare model.

The internal market and GP fundholding can be seen as a dry run for the current NHS reforms, which embody the same principles but strengthen them by reshaping the health system around them.

Dragon’s Den

‘Save the NHS’ was a key slogan for Labour in the 1997 election: its campaign played on the unpopularity of the internal market and GP fundholding. Blair’s first Health Secretary, Frank Dobson, proudly announced the abolition of both policies. But as Peter Mandelson has said, New Labour’s programme was continuous with . atcherism – and soon, Dobson and his beard were forgotten and Alan Milburn was turning the NHS into a Dragon’s Den for private providers. Webster notes that Blair did far more than Thatcher to bring the private sector into the NHS.

Facing the challenges of growing demand and innovative therapies, especially in cancer and mental health care, Milburn’s NHS Plan (2000) ushered in a new world of NHS ‘modernisation’: Private Finance Initiatives, Practice Based Commissioning, Payment by Results, Foundation Trusts (which were self-funding), and the new mantra of NHS reform: ‘patient choice’.

Under Brown’s leadership, however, the Mid Staffordshire tragedy knocked the wheels off the reform agenda. Alan Johnson, the Health Secretary left to clear up after the worst ever failure in NHS care, slowed down the transition of acute trusts to Foundation Trust status. His successor, Andy Burnham, reacted to problems with Independent Sector Treatment Centres – who withheld their performance data as ‘commercially confidential’ – by stating the NHS to be the ‘preferred provider’ of elective surgery. With language like that, you’d think he was in the Labour Party.

Here comes the son

In opposition, Conservative activists published a policy book called Direct Democracy (2005). It claimed the NHS was “no longer relevant”, and proposed a system whereby patients were funded “either through the tax system or by way of universal insurance, to purchase health care from the provider of their choice” – with the poor having their contributions “supplemented or paid for by the state”. The authors included future Health Secretary Jeremy Hunt.

In its 2010 election manifesto, the Conservatives promised an end to the relentless NHS reforms of the previous government: it would inflict no major structural changes on the NHS. Once in power, with no sense of irony, Lansley introduced his reform programme as the first major NHS reform since 1948.

However, the Cameron government learned an important lesson from the Thatcher years. The Iron Lady’s confrontational style rallied supporters, but also gave opposition a clear point of attack.

In selling the NHS reforms to the public, Cameron kept repeating two points: the NHS budget would remain ring-fenced, and NHS services would remain free. We now know that the £20bn saved under the ‘Nicholson challenge’ is going straight back to the Treasury; and Malcolm Grant has warned us that after 2015, charges for NHS services are on the cards.

So, in bringing off a health policy revolution that Thatcher would have been proud of, Cameron utilised a spin technique that carried Blair’s fingerprints: Don’t show your hand.

The NHS cost-cutting policy known as the ‘Nicholson challenge’ will be extended indefinitely beyond 2015, according to NHS England.

The Government does not expect any improvement in the economy beyond 2015, so has put in place plans to extend the QIPP agenda on a long-term basis.

The statement by NHS England’s Policy Director, Bill McCarthy, refutes Government claims that the NHS budget is ‘ring-fenced’.

However, McCarthy emphasised that the incremental cost-cutting measures that have so far been used to achieve QIPP savings will not be either adequate to the challenge or possible to keep repeating.

Instead, NHS England – through its Local Area Teams – would look at “ambitious and radical” service changes.

The LATs will need to ensure that the decisions of individual CCGs do not conflict with this national service redesign agenda, he said – further qualifying the supposed ‘autonomy’ of CCGs.

Instead of closely monitoring QIPP savings at the local level, as the DH had done before, NHS England will rate the savings plan of each CCG as ‘red’, ‘amber’ or ‘green’ based on whether it can be and is being realised.

NHS England recently published a business plan indicating that it was drawing up a framework for “major service reconfiguration”.

Malcolm Grant, Chairman of NHS England, stated recently that the next government would consider the option of charging for NHS services.

The combined statements by Grant and McCarthy suggest that a radical reduction in the availability of free NHS services is planned beyond 2005.

The NHS Quality, Innovation, Productivity and Prevention (QIPP) programme has been broken down into its components following the resignation of its leader, Jim Easton.

The role of the former National Director for Improvement and Efficiency at the NHS Commissioning Board will be divided between four other national directors and SHA leader Sir Ian Carruthers.

Easton (pictured), who has left the NHS to head private health provider Care UK, warned in May that QIPP had become a ‘label’ for NHS spending cuts without service redesign.

Then changes mean that the QIPP programme will not have a specific team or individual leader to drive it forward.

According to the Health Service Journal, the decision not to replace Easton was made to reduce the Board’s running costs and because his role had been uniquely created for his skills.

Easton’s former responsibilities will be divided as follows. Sir Bruce Keogh’s medical directorate will be responsible for a new NHS improvement body, led by the five clinical domain directors. Bill McCarthy’s policy directorate will be responsible for strategy, including medium-term QIPP strategy. Jo-Anne Wass’s HR directorate will be responsible for the new Leadership Academy. Ian Dalton’s operations directorate will be responsible for productivity improvement.

In addition, NHS South West Chief Executive Sir Ian Carruthers will take over the leadership of NHS innovation.

Global economic pressures threaten HPV vaccination programmes in the developing world, increasing the prevalence of cervical cancer, according to the World Health Organization (WHO).

HPV vaccination is among the most important cancer prevention strategies identified by WHO as needing to be implemented by governments and health authorities worldwide.

The Pan American Health Organization (PAHO), the regional WHO office for the Americas, said that by 2030 cancer cases will increase by over two-thirds worldwide, and that nearly two-thirds of cases will occur in poorer countries.

However, PAHO estimates that up to 40% of the projected incidence of cancer (21.4 million cases per year by 2030) could be prevented, and another 30% could be effectively treated, by existing healthcare methods.

On February 4, World Cancer Day, PAHO/WHO and the Union for International Cancer Control launched a global campaign for more effective cancer prevention and treatment with the slogan “Together it is possible.”

“We’ve seen a lot of progress in cancer care and cancer survival in higher-income countries over recent decades,” said PAHO Director Dr Mirta Roses. “But in lower-income countries, the cancer battle is still in its early stages. We need to step up the fight now, before cancer and other chronic diseases overwhelm our health systems.”

Cancer is the second highest cause of death (after cardiovascular disease) in the Americas, with 1.1 million fatalities each year. The most common cancers in the region are lung, prostate and colorectal cancer for men, and breast and cervical cancer for women.

Cervical cancer, caused by the sexually transmitted human papilloma virus (HPV), causes 25,000 deaths each year in the Americas. Death rates from cervical cancer are seven times higher in South and Central America than in North America.

HPV vaccination programmes have been shown to be effective in preventing the disease. But even in developed economies, austerity policies are threatening their implementation. In the UK, for example, the schools outreach programme is widely threatened by local NHS spending cuts.

Two-thirds of NHS Trusts are rationing operations in accordance with the Audit Commission’s recommendations, reducing access to hip replacement, cataract, varicose vein and tonsil surgery to the most severe cases.

Most Trusts are restricting bariatric surgery to the worst cases – a policy that a surgeon has described as encouraging obese people to gain weight.

The denial of common operations to ‘non-urgent’ cases is part of a national drive to reduce the NHS budget by £20bn over the next four years.

A survey of 111 PCTs by the health service magazine GP found that the controversial ‘Croydon list’ of procedures to be rationed has become prevalent in the NHS, despite protests from industry, clinicians and patient groups.

The prevalent cuts in surgery provision include:

• No hip and knee replacements unless the patient is in severe pain.

• No cataract operations until sight loss ‘substantially’ affects the patient’s ability to work.

• No varicose vein surgery unless the patient is suffering ‘chronic continuous pain’, ulceration or bleeding.

• No tonsillectomy unless the child has suffered from tonsillitis seven or more times in the previous year.

Two-thirds of NHS Trusts are either not providing bariatric surgery or restricting it to patients with a BMI of 50 or even 60. NICE guidelines say it should be available to patients with a BMI over 40 (or over 35 where there is a co-morbidity). The recommendation followed studies showing that weight loss surgery reduced the overall cost of healthcare for these patients.

Professor Mike Larvin, a bariatric surgeon and Director of Education at the Royal College of Surgeons, commented: “In many regions the threshold criteria are being raised to save money in the short term, meaning patients are being denied life-saving and cost-effective treatments and effectively encouraged to eat more in order to gain a more risky operation further down the line.”

Chris Naylor, a senior researcher at the King's Fund, criticised the use of rationing to save short-term costs without regard to patients’ needs and the overall cost of their care: “Blunt approaches like seeking an overall reduction in local referral rates may backfire, by reducing necessary referrals – which is not good for patients and may fail to save money in the long run.”

Chaand Nagpaul of the BMA’s GPs committee argued that Trusts rationing access to treatments on the basis of local policies meant a return to the ‘postcode lottery’. “Patients and the public recognise that with limited resources we need to make the maximum health gains and so there needs to be prioritisation,” he said. “What is inequitable is that different PCTs are applying different thresholds and criteria.”

However, a DH spokesman defended the principle of local control: “Decisions on the appropriate treatments should be made by clinicians in the local NHS in line with the best available clinical evidence and NICE guidance. What is suitable for one patient may not be suitable for another.”