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 Over 400 public health experts and academics recently wrote calling for the Bill to be withdrawn.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).
Good summary John!
Let me add a few more points. The NHS is one of the most cost effective healthcare systems in the world, it achieves this through the gatekeeper role of GPs. One of the founding principles of the NHS is “care according to clinical need, not ability to pay” and GPs have a responsibility to maintain this. The result is a distinctly non-consumerist system. Patients get care according to their condition. This is not rationing, it is a very sensible way to make sure that people do not act as healthcare consumers demanding and receiving treatments that they do not need. The result is that advanced and expensive treatments are available to everyone who need it.
Lansley’s reforms are designed to create a healthcare market and to turn patients into consumers. GPs will have an enormous conflict of interest foist upon them. GPs will now have to manage an ever dwindling NHS budget since the NHS has not been spared government cuts. The Bill will give GPs the responsibility to decide what treatments the NHS will pay for, but it will not ban them from providing for a fee the treatments that they have decided the NHS will not pay for. (A GP practive in Haxby, Yorks are already doing this: denying care on the NHS but offering patients the treatment for a fee.) On international standards the UK’s GPs are extremely well paid (the OECD says too well paid) yet this policy will allow them to be paid even more. Further, the Bill will offer the misnamed “quality premium” for GPs who ensure that their practice remains in budget. This will mean that a patient will not know if the decision of the GP is clinical, or financial. Has the GP decided not to refer the patient for further treatment because clinically they do not need the treatment, or because the cost of the treatment will push the GP practice over budget and so threaten the GP’s “quality premium”? This is frankly a disgusting conflict of interest.
There are issues about the organisation of the “pathfinder” clinical commissioning groups. International comparisons with other countries in Europe and with the US show that primary care commissioning groups are financially non-viable and ineffective if the populations covered are small. A population of about 300k is viable, and this was the median population covered by the Primary Care Trusts the bill will abolish. The median size of the new CCGs is about half that at 170k. 60% (161) cover populations less than 200k, a quarter cover less than 100k. These smaller CCGs will have to merge with other groups in the next few years, meaning more upheaval that will result in sub-optimal care for their patients. A competent Secretary of State would have used international evidence and stipulated a minimum population to avoid the creation of such CCGs that will fail in the first few years.
As to FTs being able to take on private patients, some stats are required to illustrate the point. The existing FTs (about 2/3 of hospital trusts) generate 1.1% income from private activities (not necessarily from private patients). However, a few specialist (mostly London-based) hospitals have large private patient incomes. The Royal Marsden has 30%, Moorfields Eye Hospital has 18%. During the last decade when the country was awash with money the proportion of total healthcare spent on private healthcare was static for the entire decade at about 20%. Unless the government slashes the proportion paid out of the public purse (not a totally unlikely possibility) this proportion is likely to remain. The fact is, my local acute hospital trust which has 1.3% of its income from providing pathology services to a nearby private hospital, is unlikely to increase this income. There are not the private patients with the money available. However, specialist hospitals like the Royal Marsden and Moorfields which currently have their private income capped will be able to get more private patients when the cap is removed. The result will be fewer NHS patients. That means NHS patients will be effectively priced out of world class treatment.