The National Health Service in England is facing far-reaching changes which many opponents fear could spell the end of a system that has for over 60 years won admiration around the world. A highly controversial Health & Social Care Bill presented to Parliament in January by Health Secretary Andrew Lansley is now being debated in detail in the House of Lords.
Although innocuously described in some BBC reports as “giving more power to GPs”, the Bill would fragment the health care system, reducing the National Health Service itself from a public service, largely publicly provided, to little more than a collective fund of taxpayers’ money to buy services from a range of for-profit and non-profit providers in a competitive market.
The Bill proposes to scrap all 160 or so local and regional management structures (Primary Care Trusts and Strategic Health Authorities) which currently commission health services for large populations. It would also dilute the responsibility of the Secretary of State for the provision of a universal and comprehensive health service in England. Existing scrutiny arrangements over local health services are also scrapped.
Public health responsibilities would be hived off to local government, to be run by new “Health and Wellbeing Boards” – which may contain as few as six people. Over 400 public health experts and academics recently wrote calling for the Bill to be withdrawn.
The £80 billion annual NHS budget for commissioning health services in England would be devolved to new GP-led “Clinical Commissioning Groups” (CCGs). Hundreds of CCGs have already sprung up in advance of the legislation being agreed, despite 78% of GPs opposing the Bill: only 16% want to be involved with commissioning. Just 7% of CCG leaders were subject to a contested election.
“Pathfinder” CCGs have been set up without public consultation or involvement. Cuts in spending mean they will become rationing boards, deciding what services to exclude from the NHS. CCGs are not required to work together, threatening greater inequality in access to care between one area and another, and conflicts of interest for GPs with private sector connections.
Despite all Lansley’s hype, GPs will NOT really be in charge. CCGs will be dominated by a remote, bureaucratic NHS Commissioning Board. Its new chair has already declared the Bill “unintelligible”.
All the real work of commissioning will be done by management teams, many of them from private companies. In London 31 CCGs have signed an initial £7m deal with consultancies including McKinsey and KPMG, for assistance – a prelude to taking over almost every duty GPs are supposed to carry out as commissioners.
Patients requiring hospital care will have even less choice than now. Hospital referrals will require the rubber stamp of cost-cutting “referral management” teams, often run by private companies, many staffed not by doctors but by podiatrists and nurses – with power to over-rule GP and patient choices.
The Bill would open up many clinical services to competitive bids from “Any Qualified Provider” – private companies, inexperienced voluntary groups and unstable social enterprises – jeopardising the quality of care. GPs will have no say over which providers will be included in the national register of qualified providers, drawn up by the independent regulator Monitor.
More private providers entering the market as the NHS seeks £20 billion in “savings” will inevitably bankrupt many local NHS services and hospitals.
Meanwhile all NHS providers will have to become autonomous Foundation Trusts, run outside of the NHS framework as non-profit businesses and accountable to Monitor. Foundation Trusts would be allowed to make as much money as they like from private medicine, treating wealthy patients from home and abroad – while NHS budgets are squeezed and performance targets relaxed.
The Bill could cost at least £3 billion to implement. It remains hugely controversial and may yet be amended in committee stage discussion in the Lords.
Every week it drags on does more damage to David Cameron and the Conservative Party, for whom the NHS – and the Bill – have once again become a toxic issue.
Despite defeatist MPs, peers and others arguing much of the Bill is already a fait accompli and must be accepted, GPs are still unmoved: and 84% of psychiatrists oppose a Bill which would threaten services for their vulnerable patients. The Academy of Medical Royal Colleges reports “united opposition” of its members to aspects of the health bill – notably the proposals to promote competition. All health trade unions and professional bodies are opposed, and even the normally docile Patients Association has raised fears of Lansley’s Bill.
So it’s more or less unanimous on all sides: thousands have marched and tens of thousands have petitioned. Ministers have ignored all protests. But as evidence mounts to show how Lansley’s Bill would open up a weakened and fragmented NHS to the private sector, campaigners are fighting on to force amendments that reduce the damage – or preferably kill it off altogether.
But the Bill stands as a warning to the world that even long-standing and successful services could be put at risk by ill-conceived neoliberal market reforms, for which there is no serious supporting evidence.
John Lister is a freelance journalist with over 27 years’ experience in analysing health policy for pressure group London Health Emergency, and now senior lecturer in Health Journalism at Coventry University. His PhD is in global health policy, and his books include Health Policy Reform, Driving the Wrong Way? (2005) and The NHS After 60, for patients or profits? (2008).