THIS IS A LATER VERSION OF THE FIRST PAPER AGAINST LANSLEY’S BILL OF 2010
The Health and Social Care Bill 2011
Why it should continue to be fought
January 28th 2012
I had profound concerns about the Health and Social Care Bill1 when it was first published, became more worried by the sham of the so-called “listening pause” , and now it has passed through most of the stages in Parliament , reaching the Lords Report Stage in February , like many of my GP colleagues, I believe more strongly than before that malevolent forces will ensure this is the end of the NHS in England. As a family doctor for nearly 30 years and having worked through at least 15 NHS “re-organisations” , none have threatened the NHS as much as this , and the amendments proposed do not diminish that threat. In fact some “tacked on” by the Government recently such as allowing 49% of hospital work to be private just confirms their destructive aims.
The Bill radically reforms the way the NHS is run in England and undoubtedly will lead to privatisation , despite denials
A thorough read of it’s 354 pages (three times longer than the 1948 NHS Act) exposes the Government’s plans to replace the NHS system of public funding and mainly public provision and public administration with a competitive market of corporate providers in which Government finances but does not provide healthcare. It paves the way for a commercial system in which the NHS is reduced to the role of government payer , like the Medicare and Medicaid schemes in the US.
The give-away is the Secretary of State’s desire to shed his obligation and responsibility for ensuring provision of a comprehensive health service and to not lay that obligation onto anyone else. Despite the NHS Future Forum report 18 released on 13th June , the Government’s response does not reverse this—it being an essential requirement for privatisation. The NHS Act 2006 currently states “the Secretary of State must provide or secure the provision of services”. It is not reassuring that this has been changed to “the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided”. If it does mean the same , why change it ? Introducing charges for patients has been ruled out for this parliament. And just changing the name of Consortia to “Clinical Commissioning Groups” is repackaging only . The Bill is now a re-spray job on two “right-offs” welded together , with hundreds of alterations ( amendments).
Aspects of the Bill, such as the greater involvement of clinicians in planning and shaping NHS services, have the potential (if implemented well) to improve patient care and this alone has seduced many into thinking the Bill is a step in the right direction. But GP commissioning is a smoke-screen and if that was really the main aim of the Coalition Government , wouldn’t require primary legislation. Like any bad insurance policy , the devil is in the detail of the small print. Some clinicians are keen to be a part of planning , but not an instrument of privatisation. The benefits that clinician-led commissioning can bring are threatened by the Bill’s main purpose , and the latest idea of introducing “clinical senates” which will have the key role of advising the NHS Commissioning Board on whether plans are clinically robust reduces the effectiveness of this even further. Of particular concern is:
- Enforced competition: The original version of the Bill was to force commissioners to tender contracts to any willing provider which would destabilise local health economies and fragment care for patients. Watering this down and changing the name to “any qualifying provider” fools no-one. The doctors who are responsible for commissioning should be free to work with hospital and community care colleagues and patients to develop the care pathways that, in their clinical judgment, provide the best care for their patients, without fear of a challenge from the new NHS economic regulator, Monitor. Shifting the responsibility of promoting competition to the Commissioning Board still leaves all the levers for privatisation in place. Originally clauses 63 and 64 of the Bill would have forced consortia to open up services to competition that they have designed in co-operation with their secondary care colleagues. The private company CircleHealth has already challenged PCT decisions . Commissioning is not shopping. The relationships we as GPs have with our consultant colleagues are essential to whether we refer patients to them. We do not refer to buildings but to people. The declared preference of Monitor’s chairman David Bennett (formerly of KPMG and McKinsey) for chains of Tesco-style hospitals2 exposes a sad and fundamental misunderstanding of how the sick should be cared for. His intended role may have been altered to deflect away from this , but it will still happen if unchallenged. Competition is of dubious cost benefit compared with the collaborative model of healthcare. It works when selling groceries, but when the grocery store fails food rots and people lose their jobs. It hasn’t been explained what happens when hospitals fail, which in the intended free market some inevitably will.
There is no evidence the market benefits healthcare . Most of the many re-organisations have occurred since the market was introduced , and the reason for their need is simply that the market does not work in healthcare so constant experimentation is required .
Doctors should be joined by patients and local authorities in the planning , but not necessarily the commissioning , of services, and to attach others as proposed by Professor Field18 who are “out of area” and thus have no local knowledge is making a pig’s breakfast into a dog’s dinner.
- Price competition: Admittedly there has been some backtracking on this by Andrew Lansley, but this seems at odds with statements by Monitor’s Chairman. An amendment has been suggested by the Secretary of State , but price competition will remain just a step away. It is not a proper market without price-competition. The original Bill would allow providers and commissioners to agree prices below the tariff set by Monitor (to be paid for different sorts of treatments), opening the door to price competition. ( This is clear in Clause 103 which states there will be maximum national tariff pricing ) .Such a move could allow some providers to chase the most profitable contracts, possibly using their size to undercut on price, which could ultimately damage local services. Every shred of evidence shows that price competition leads to a reduction in care quality3. Ask any consumer of gas, electricity or user of the railways if they are happy and feel treated fairly (except the shareholders). Reassurances that this will now not be in the final legislation won’t convince those who were duped in the same way over tuition fees. And fixed pricing is anti-market , so can’t possibly last long. Although the Government in paragraph 5.16 of it’s response to the NHS Future Forum says it “will maintain the present competition rules for the NHS” Mr Lansley has refused to publish the legal opinion he has obtained on the effects of European Competition Law.
But my other concerns and reasons for opposing the Bill are that it is
- Unnecessary : What is the problem the Government feels needs a massive revolution to fix ? Mr Lansley continuously quotes “evidence” to back his theories but his inaccuracies and false conclusions would have him failing a GCSE15 The NHS has the highest approval rating ever. Mr Lansley’s main reason for introducing such untested change is that we have poorer health outcomes than, for instance, France. These claims have been largely discredited4-9. He persists with these false claims however as it exploits public fears in an effort to make more acceptable changes that would otherwise be regarded much more negatively . Myocardial Infarction rates are indeed higher at present but on the current trends UK death rates will be lower by next year (and France spends 29% more on healthcare). Rates fell faster than in any other European country between 1980 and 2006. Cancer death rates are also selectively quoted to suit his argument . If present trends continue the UK will have a lower breast cancer death rate than France in a few years. Lung cancer death rates are lower and there have been improvements in the 5 year survival rates of nearly all cancers. Mr Cameron has recently tried to help out quoting Zack Cooper who claims competition lowers myocardial infarction rates –this too has been discredited. In fact the Prime Minister seems unaware of what his Health Secretary is up to. Recently the PM has praised the improvements in stroke care brought about in London as a result of concentrating care in fewer hospitals , seemingly unaware that these improvements had resulted from the Healthcare for London programme that his Government terminated soon after coming into office. He is clearly nervous of the potential major political penalties risked by allowing his well-informed but tunnel-visioned privatiser Secretary of State , who is close to the private health industry, pushing ahead with the Bill.
If serious about “outcomes” Mr Lansley would do well to study the evidence from the UK and overseas that repeatedly shows that strong primary care produces better outcomes, better patient satisfaction and lower health costs.
The UK polled highest (93%) compared with European countries and the USA when asked about the ability to access a doctor on the same or next day , and when asked to rate the care they received from their usual doctors , the UK came second with 79% rating care as very good or excellent . But with the gradual erosion of the GP as the first point of contact , together with current Government policy of more competition (under the guise of more patient choice) our future as providers looks uncertain as competitors circle to compete against us. All at a time when GPs are to be given responsibility for large amounts of health service spend. Around 300 million consultations take place annually in general practice with only 1 in 20 ending up with a referral to secondary care. Ironically , this compares with 37% of patients in the USA being referred per year against 14% of UK patients10 . More reasons for avoiding the lemming-like rush towards an American-style system.
New research in the Journal of the Royal Society of Medicine shows that the UK is the most efficient health service in the World in lives saved per pound spent.39, 40
The budget deficit is used as an excuse too. It needs to be pointed out that this country was bankrupt after World War Two with a much bigger deficit ( a national debt of 180% of GDP) and managed to create the NHS out of the rubble. The present UK figure of 60% compares favourably to many other countries including to 71% in the US , and 194% in Japan.
When doubt is raised about whether we can afford the NHS, the motives of those asking the question should be scrutinised. Think through the logic very carefully.
Unaffordable to who?
If to the Country as a whole , the claim is that one of the richest nations on earth cannot look after the health of it’s citizens.
If unaffordable to the Exchequer you are exposing your philosophy and priorities as to what tax is spent on, as healthcare through general taxation is the fairest, most effective and cheapest way
—all other systems would be even less affordable
You would be agreeing that we abandon universality and the comprehensive nature of the NHS, and we accept 2 tiers of healthcare in this country
If unaffordable to the citizen we go back to the dark ages , pre-NHS ,with the state leaving people to their own devices. This then becomes a 3 tier system like in the USA
If we can’t afford the NHS in it’s current form or any other form, we will need an additional system. Add the cost of that, whether it be insurance based or whatever and the citizen ends up paying alot more . The total will be far greater than the cost of even the most comprehensive NHS.
Those who have never liked the NHS have peddled this “we can’t afford it” nonsense since 1948. What they really mean is they don’t want to pay for it. As Appleby states38 , spending on health is a matter of choice, not affordability. Yet again, Lansley inadvertently exposes his hand.
There is evidence that Ministers have been “burying good news” about the NHS because it will undermine their case for these sweeping reforms. The polling organisation Ipsos MORI submitted results last autumn to the Department of Health that shows record levels of satisfaction with healthcare– a finding contrary to the health secretary’s insistence that it is falling short and needs urgent change. Withholding this unpublished polling data fuels accusations that the government is rooting out negative statistics about the NHS to justify its reforms. But, slow to learn lessons a new paper just published by the Department of Health16 is still trying to make the case for the reforms using statistics over 20 years old, misleading claims about NHS staffing and completely inaccurate false extrapolations about “choice” 17
The Government has failed to explain why the NHS, ranked overall second in health outcomes and first in cost-effectiveness among seven developed countries (UK, New Zealand, Canada, Germany, Netherlands, Australia and the US) needs to involve profit-making providers.
Of 887 responses to the “Your views : Choice and Competition” section of the Future Forum , part of the recently completed Listening Pause , 597 were against choice and only 17 (which included an NHS chief executive and someone living in France) in favour . The Government’s spin on this was that “nearly everyone who contributed to the listening exercise felt patients should be given more choice” . If that isn’t a blatant lie , it is difficult to know what is, and clearly leads to questions about the Government’s motives.
Why also should they suppress the Department of Health’s Strategic Risk Register outlining the risks that Lansley’s reforms pose to the NHS? He has refused it’s release under the Freedom of Information Act. However the information commissioner ruled on 2/11/11 that it should be disclosed45. We are still waiting.
- Scale and pace of change: At a time of huge financial pressure, these major, untested reforms are, undoubtedly, a massive gamble. For instance rushing all hospitals to Foundation status could lead to a focus on achieving financial stability rather than maintaining high quality patient care. Boards of GP Consortia are being elected in some areas before GPs have had a chance to understand what is going on. This has resulted in some Boards consisting of a group of almost self selected GPs (as few if any stood against them) with their constituents being unaware of their plans or ideology. Some have issued constitutions which are not actually needed yet. These have included long lists of “obligations” which member GPs have to obey or risk being expelled . Other clauses threaten to expel GPs with immediate effect if they express views or act in ways that are contrary to or damaging to the aims of the consortium . Professor Field’s suggestion of slowing the pace doesn’t make a bad idea any better18.
Two polls11 have shown at least 60% of GPs against the Bill and more than 7 out of 10 disagree that “any willing provider” would improve health outcomes. If the market is to remain we need to focus on enough excellent providers and not lots of any “willing” providers—calling then “qualified” providers shouldn’t be necessary , or is there a danger of using unqualified providers ? But as shown , it is only those with this privatisation agenda who are telling patients they want choice , and therefore need loads of competing providers (extremely wasteful) when what they really want is a good efficient clean local district general hospital. Claims that GPs are falling over themselves to become Pathfinders is mischievous and devious. In my area, like most , a few enthusiasts are pushing ahead , and as it is compulsory , the rest of us are being dragged along. This allows Mr Lansley to claim, falsely, that 252 GPs are keen, covering about 361,000 patients. By extrapolating this he repeats that the vast majority of patients served by the vast majority of GPs are behind his reforms. If a genuine unbiased survey were carried out (which the BMA are considering) this would be shown to be a lie. Just because GPs are manning the lifeboats doesn’t mean they are in favour of the deliberate sinking of the NHS Ship. In fact , the truth is that there is a staggering lack of GP engagement with 95% of GPs appointed to the boards of the new clinical commissioning groups (CCGs) not having faced an election41. And a Secretary of State who appoints a “listening panel” of 40 with only 5 GPs on board , all in favour of the reforms and mostly “pathfinders”, cannot even have confidence in his own arguments if having to resort to tricks like this. None of the others can claim to be independent. Professor Field is a well-known long-term proponent of marketisation. No wonder politicians are not trusted by the public.
A MORI poll12 of all doctors reveals that 89% believe increased competition will lead to service fragmentation and 65% that it will reduce the quality of patient care , increase health inequalities and damage NHS values. 61% believe the reforms will lead to them spending less time with their patients. Current estimates of between 600-1500 full time equivalent GPs being removed from patient care to deal with the commissioning agenda will exacerbate the inverse care law29 that currently applies to GP provision—where areas of greatest need have less GPs per head of population. The Bill does nothing to address this unfairness – in fact quite the opposite.
The risk is that the enthusiasts may think that they are championing the health needs of their patients when in fact what they are actually doing is sanitizing unacceptable decision making—such as the compulsory use of referral management centres , restricting patient access to specialist care and implementing stringent cuts in front line health care.
55.8% of those GPs recently surveyed who intend to retire in the next 2 years cited the NHS reforms as the main reason31.
The Royal Colleges have recently stepped up their opposition to the health bill to reflect the strong concerns of their members. Three quarters of GPs 42 and 84% of psychiatrists think that the bill should be withdrawn , according to surveys published as the bill was being debated in the Lords. Only 4% og GPs and 12% of psychiatrists agreed that the reforms would result in better care of patients. 67% of GPs and 78% of psychiatrists do not believe the Bill will improve relationships between them and 78% and 86% respectively thought it would not reduce bureaucracy in the NHS. Only 16% of GPs and 27% of psychiatrists wished to be involved in clinical commissioning at either a local or national level.
It seems that when things go wrong , GPs will now be blamed. Professor Malcolm Grant , who is the newly appointed Chairman of the NHS Commissioning Board told the Health Select Committee on 18th October 2011 that GPs in the new clinical commissioning groups should take responsibility for any failures and budget overspends44.
The latest survey by the Royal College of GPs 46 found that over 98% felt the College should call for the Bill’s withdrawal. 60% felt more negative about the effects of the Bill on the NHS than at the last survey, and 90% said the reforms would increase the involvement of the private sector. More than three quarters said bureaucracy would not reduce , and less than 14% believed better care for patients would result.
- No mandate : Andrew Lansley gave a pre-election pledge that there would be no major re-organisation , but the Head of the NHS Sir David Nicholson says this is so large it can be seen from space. It is disingenuous to claim it is in the Coalition Agreement—no-one voted for that. Furthermore, the Coalition Agreement promised “to stop top-down re-organisation of the health service”. This promise has clearly been broken and to give just one example where central control will remain is in the detail of the Bill where Ministers and the NHS Commissioning Board retain too much power over GP Consortia. There is not even any requirement in the Bill to consult with a Consortium or the public it serves if the regulators dissolve a Consortium. Nor is there any recourse for appeal. Clause 16 actually proposes that the Secretary of State will be able to “require consortia to do whatever he/she deems necessary for the purposes of the health service” He will certainly have too much control over the NHS Commissioning Board being able to make changes without consultation and dictate how and which treatments and services consortia provide. So much for devolving power . In response to the NHS Future Forum’s recommendations the Government says the NHS Commissioning Board will only intervene in the case of “significant failure” . Who judges what this is ? The abolition of PCTs and SHAs appeared out of the blue months after the Coalition Agreement was signed. Westminster sources state that No 10 Downing Street was unaware of this policy even the night before the Bill was published.
Those of us who believe in the founding principles of Nye Bevan’s NHS were disenfranchised at the 2010 election as all three main political parties backed the market in healthcare policy and the Neo-liberalism strategy. To claim that these principles are maintained by it still being (at present) free at the point of use is to ignore the importance of the universal and comprehensive elements which were critical to Bevan and just as relevant today. There is no mandate to abolish these key elements, but they are on their way out—perhaps the Government has no understanding of their importance , being so obsessed with competition and commercialisation. As stated above the duty of the Secretary of State to provide a comprehensive health service in England is abolished –the duty was to be changed to “promote” in the original Bill but has been altered again. Clause 9 abolishes the duty on the health secretary to “provide (certain health services) throughout England”. A consortium (or Clinical Commissioning Group , as they are now to be known) does not have a duty to provide a comprehensive range of services but only “such services or facilities as it considers appropriate” (Clause 10,1) It also can determine which services are part of the health service and which are chargeable (clause 9) and they have been given a general power to charge (clause 7,2h). Where is the mandate for this ? No wonder those now in power did not want to discuss the NHS during the last election campaign.
There is clear evidence that the course was set for privatisation in the early 2000s and this Bill is the final piece in the jigsaw and will turn out to be the final nail in the NHS coffin 27
No-one voted for the privatisation that was carried out under the last Government , namely the Independent Sector Treatment Centres, the privatising of GP services through APMS , Darzi polyclinics, selling NHS Logistics to DHL, oxygen supplies, pathology services, ambulance services, off-shore medical secretaries and the independent sector use of the NHS logo (as if that would lull the public into a false sense of security). Few are aware that a Commercial Directorate was set up in 2003 by New Labour. These underhand activities do nothing to help the reputation of politicians. Cataract operations at a private treatment centre in Oxfordshire cost 600% over the odds. The ISTC was forced on the local NHS by the Department of Health but performed only 93 of the 572 contracted procedures in half a year. Meanwhile eye operations at an ISTC in Portsmouth have cost seven times more than they would on the NHS.21,22 There are numerous other example including in my own area.
Novation is DHL’s subcontractor which runs NHS Logistics. There are serious outstanding allegations against Novation in the US. The Department of Justice is currently investigating the company over bribery and defrauding American public health schemes.23 There is also a wealth of evidence to suggest that Novation’s activities inflate the price of medical supplies in the US24
Oxygen supplies have been privatised and are now run by four multinational companies (BOC ,Linde, Air products,and Allied Oxycare/Medigas). The cost has rocketed.
Private Finance Initiatives are one of the biggest scandals to affect the taxpayer. NHS hospital Trusts with PFI contracts spend up to 18.6% of their annual income servicing the cost of privately financed investment ; this money goes to the private sector34. £11 billion-worth of PFI building projects will cost the tax-payer for decades to come over £ 65 billion35 . The audit office judged that some trusts were paying more for PFI services than they need but could not investigate as after 2008-9 the “NHS stopped collecting data” 36. Curious that the Government think it more important to collected data about the temperature of the fridge in my surgery than on something costing billions. The Government rescue of banks to the tune of hundreds of billions presents an ideal opportunity to reopen the contracts. McKinsey37 estimates that a reduction of only 0.02-0.03% in interest charges would save trusts £200m a year . So why the reluctance if the Country is in such financial trouble ? In our area the new Pembury Hospital costs could bankrupt the local NHS and will certainly necessitate the running down of Maidstone Hospital to help pay for it, as we have seen.
- Inefficient and expensive : The Secretary of State’s claim is the reverse , and the Prime Minister continues to claim the reforms will save money 30. But the health service still needs managing and many staff made redundant when PCTs and SHAs are abolished will need to be re-employed by GP consortia. This too has not been denied by the PM30 and some of the £852 million spent on redundancies so far will go into the pockets of those re-hired.. Furthermore the “market” will require a whole new army of bureaucrats , economists ,lawyers and accountants. There will be seven layers of management. The current number of 163 statutory bodies will rise to 521 , contrary to the Government’s declared aim of reducing the number of quangos. The biggest part of the Bill ( Part 3 amounting to 8 chapters) covers the red tape of economic regulation. The market is inefficient. International evidence unequivocally demonstrates that markets in healthcare distort access, promote inequity, and diminish choice and quality. They encourage unnecessary interventions and consequent damage to patients. The administrative costs have risen to 14% , from only 5% pre-marketisation.
Matthew G. Dunnigan has studied clinical activity in the English and Scottish NHS before and after Devolution25 . Hospital admission rates , referral rates and A+E attendance rates ran low and parallel until the introduction of Payment By Results in England. Since then and the expansion of the market in England , rates have pulled significantly ahead in England. Up to 2009/10 hospital admission rates in England were up 26% (compared with Scotland’s 0.8%) , referral rates up 67% (compared with 5%) and A+E attendance 46% (compared with 12%). These are the Government’s own figures.
In 2006 the Netherlands introduced a mandatory private insurance system similar to Switzerland. Advocates argued that competition would reduce health spending, enhance “consumer” choice, and improve quality of care and the health service’s responsiveness to patients. The reality has not matched the rhetoric and has fallen short of expectations.26 14.8% of GDP is now spent on health , insurance premiums have gone up 41% ,and the new system has produced high administrative costs. The “choice” agenda has proven false with only 4% changing plans. Four insurance conglomerates control 90% of the Dutch health insurance market. Opinion polls show 65% of the public have low or very low levels of trust.
The market does negatively interfere with patient care. In the last 10 years we have seen increasing “gaming” by Acute Trusts to claim more fees. Patients who are close to “breaching” the 4 hour A+E wait are needlessly (and dangerously) admitted to hospital to help statistics and to get a high admission fee from their PCT. Often nothing is done and they are discharged a few hours later. GPs are being asked to re-refer patients for follow-up after having already referred them. Another fee. The fragmentation of specialist care into different “parts of the body” requires multiple referrals instead of joined up care in the interests of patients. For example, a patient presenting with a difficult to solve abdominal pain problem, may be referred to an upper gastro-intestinal surgeon, but if that specialist rules out pathology in “his” bit of the body will send back to the GP, who then might have to initiate another referral , to perhaps a lower GI surgeon, then perhaps a gastro-enterologist and so on—significantly delaying the care that patient needs. Certainly not seemless care , and the potential for numerous administrative mistakes.
- Unfair : The logical result will be different levels of healthcare for populations in different areas , the creation and entrenchment of more so-called “post-code” lotteries , and ultimately a system where top-up insurance is needed for comprehensive health cover, thus producing, not a two tier , but a three tier service. As already mentioned , the Bill will exacerbate the inverse care law27.
- Damage to the doctor-patient relationship : This is fundamental and of great concern. Few outside the profession really understand the problems created by the influence of money on clinical decision making. Many have the impression that “if it’s paid for, it must be better”. Nothing is further from the truth. Unethical practice is endemic in private medicine. It leads to over-investigation , over-treating, and more bureaucracy ,when often the best medicine is no medicine. Private care is measured by activity which is no measure of quality, a fact that seems to have escaped recent Health Secretaries At present the GP is still the patient’s advocate and most know that we are acting in their best interests. Doctors repeatedly rank highest (88%) 32 in the public’s trust with politicians stuck at the bottom (14%) This has been earned over the years because the public know their NHS doctor has no financial axe to grind. Trust in physicians in the US is a lot less under a system where finance is the elephant in the consulting room. Trust will suffer if suspicions arise that investigations, treatments or referrals are not happening for financial, not clinical reasons. Rationing is being “dumped” on us as no political party has ever had the courage to tackle it. The cynic in me would claim that politicians rarely give up power voluntarily unless there is a benefit to them. The benefit they get is that they pass on a “poisoned chalice”. But they are retaining power through “smoke and mirrors” where it suits them, whilst continually claiming it is being put into the hands of the clinicians. Those seduced by this will soon learn how little power they actually have.
GPs are being told to no longer put the interests of the patient sitting in front of them first but to think of the community and what the local NHS can afford. This is asking for a relationship going back to Hippocrates to be changed , and is unacceptable It should be , and will be ignored by the vast majority. Of course this will fundamentally damage the doctor-patient relationship.
The result of the change in the way health care is provided in England will be the bizarre mixture of patients eventually realising they are inappropriately under treated at the GP end of help, but inappropriately over treated when they get through the barriers to their private provider. That does nothing to help build confidence between patient and clinician. Poor clinical decisions will be made and patients suffer if professional autonomy is eroded by referral management centres run by corporate providers who have as their main goal ensuring referral and prescribing practices conform to corporate budgets (clause 12,1) and the needs of shareholders. Some of these centres, such as UnitedHealth UK’s referral facilitation service in Hounslow, are run by subsidiaries of US multinationals.
The proposed “Quality Premium” rewarding for “effective financial management” is unethical as it can be abused and will be. Clause 23 does not set out the process or criteria used to judge the relative contribution of different members of the consortium when distributing “performance related payments”. This omission could lead to worrying manipulation. In the same clause the Bill explicitly authorises the creation of surpluses from the patient care budget and their distribution to staff and shareholders as part of financial incentive or bonus schemes. The Government has responded to this criticism by stating this will be revised , but not commitment to changing the principle.
One GP in 10 on the boards of new commissioning consortia also holds an executive-level position with a private provider, exposing the serious potential for conflict of interest. Almost a quarter of consortium board members have some kind of interest in private providers, with others either shareholders or advisers . Companies like Integrated Health Partners have hinted that profits can reach GPs through a few “twists and turns”.
Conflicts of interest are built into the system. One of the UK’s largest private providers of GP care (The Practice plc) has made it’s most significant inroad yet into commissioning after NHS Buckinghamshire handed it control of budgets for outpatient appointments and prescribing33. It already runs 60 surgeries and recently acquired the UK provider arm of the US healthcare giant Unitedhealth. As the company ,like many others, has a role in both commissioning and providing , there is a clear conflict of interest. Patients will inevitably be directed to clinics run by the company. Safeguards will be easy to get around, as the corporate world has much experience and imagination in side-stepping regulation. It will be analogous to , instead of outlawing bank robbery, putting a notice on the door saying “no robbers allowed”
- Confidentiality : When the public wake up to the lack of safeguards for their confidentiality the Bill’s supporters will have to face much anger. The Bill gives broad powers to bodies such as the NHS Commissioning Board , the NHS Information Centre and the Health Secretary to obtain and disclose confidential patient information for a number of unspecified purposes. Fears that data may be shared with others may result in patients withholding important information. This may not only affect their health, but has implications for the wider health service.
By failing to put in place proper safeguards, the Government is potentially removing the control doctors and, most importantly, patients have over their confidential data. This conflicts with Government promises that patients will be given greater control over their medical records. The Government has responded to this by stating consideration will be given to how to amend the Bill to protect patient confidentiality. This is another clear example of a rushed , ill-thought out piece of draft legislation.
- Education and Training: At present training and workforce planning is organised regionally by SHAs, but with their abolition this will be commissioned by individual Trusts. It will become too “local” with no strategic planning and so probably lead to waste and inefficiency by duplication . Workforce planning will suffer as it will be squeezed from the priority list by the necessary pre-occupation with day-to-day problems. The long term needs of the population will be relegated down the list. Trusts will no longer see the value of taking on doctors in their foundation year. Private sector providers will certainly not want to employ newly qualified doctors. There is a strong possibility that not all departments, or even whole trusts, will be training units. The current proposals suggest that such decisions may well be made for business rather than educational reasons.
The Government has acknowledged that the impact of the reforms on medical education and training has not been sufficiently thought through. Again, extremely worrying that our legislators show such a level of incompetence.
- Commercialising healthcare is bad for health—both for the individual and community. There is no evidence at all that private companies are more efficient or lead to better outcomes. There are some good local examples where “outsourcing” (often the euphemism for privatisation) has produced a service for patients that can only be described as pathetic (for example counselling and cataract services. The former “ticked it’s contract boxes” and was able to claim that it had dealt with a referral by ringing patients and telling them to buy a book from Waterstone’s! They “cherry-picked” easy cases, refusing to see certain well-deserving patients in need. The Cataract service disappeared overnight, abandoning patients). When the public realise the extent that shareholders are making profits out of healthcare at the expense of the taxpayer and in principle this differs little morally from bankers taking home large bonuses from the public purse, there will be a tidal wave of anger.
Disturbingly, Clause s12 specifically enables privatisation of high security psychiatric services. It must cause concern to any rational person that the provider of these services will be expected to prioritise shareholders’ pockets before public welfare. It was the privatisation of hospital cleaning that brought us deaths from methicillin resistant Staphylococcus aureus , and the balance sheet problem that led to at least 90 deaths from Clostridium difficile in the Maidstone and Tunbridge Wells NHS Trust between 2004-2006. As mentioned above , to be able to pay for a new PFI hospital in the same Trust (at Pembury), Maidstone Hospital had to sack cleaners, close wards and push beds closer together—no wonder infection rates took off and tragically there were deaths as a direct consequence.
Increasingly, general practice and commissioning functions will be operated and managed by for-profit companies , 23 of which (including Virgin, Care UK and Chilvers McCrae) already run 227 general practices13.
Reynolds19 (from the London School of Hygiene and Tropical Medicine) explains how for-profit companies will strip NHS assets under the reforms “ leading to a more expensive system that will deliver worse quality of care”. Their duty to their shareholders requires them to cherry-pick the most profitable services at the expense of the rest , and to spend as little as they can get away with on the service provision to maximise dividends. They have no interest in the social or ethical dimensions of healthcare. Southern Cross , which is threatened by insolvency, claims it can cut 3,000 jobs without affecting patient care . If true the company has been charging councils, and residents who fund their own care for unnecessary staff.
Fifteen clauses (ss125-131,168-175) collectively create a new insolvency regime for hospital foundation trusts. Why is this a priority in NHS Reform ? Clues emerge in clause s 293 which removes the prohibition on sale of NHS assets , and in s160, which allows foundation trusts to raise loans for the first time. The Government remains mute as to the purpose of these innovations , but their passage would enable private equity companies to buy NHS facilities and asset strip them. The Bill bans the Government from stopping them.
Too many politicians , including several former Secretaries of State for Health, have links with private healthcare providers. So do numerous “health advisers” to this and the last Government. Most of these companies have no experience of UK general practice, but a lot of experience of making money. And now we learn that private companies look set to be offered seats on the all-powerful NHS Commissioning Board.
The Bill will have the most significant impact on the future of NHS services, its workforce, and public health. Eventually, whether the intention or not, a state monopoly will be replaced by a corporate cartel big enough to bully parliament and suffocate true competition. The food industry is analogous, with a handful of large companies monopolising and dictating, delivering some of the highest prices in Europe. Large public institutions represent a lost opportunity for corporate profit. By and large these public institutions , like health and education, are valued and loved, so simply privatising them in a transparent way is political suicide. So we have a new model. The public institution apparently remains intact but actually becomes an empty shell that commissions services from private corporations.
I believe the way a society delivers its healthcare defines the values and nature of that society. The NHS is extremely popular with the British public, and these reforms will destroy a 63 year old National treasure against the wishes of the vast majority. All the Celtic nations have woken up to this and got rid of the market and the English need to do the same. The “National” will no longer be an appropriate initial in the title NHS, but even worse , the H for health will be replaced by a B for business. NHS will be a mere logo or kite-mark attached to selected services. In the USA , healthcare is not primarily about looking after the Nation’s health, but a huge multi-company money making machine. That defines their society. The USA pays twice as much yet lags behind other wealthy nations in such measures as infant mortality and life expectancy where it stands 48th in the World. More money is spent per person on healthcare than in any other nation. The World Health Organisation has ranked the US healthcare system as the highest in cost , 37th in overall performance and 72nd by overall level of health amongst the 191 member nations surveyed As Mr Lansley is so keen to justify his revolution on the basis of health “outcomes” he should take note of these particular outcomes before dragging England towards an American style healthcare system which has been described as islands of excellence in a sea of misery. The contrast is of a caring society which looks after the weakest and sickest with a dog-eat-dog survival of the fittest, where money rules.
The irony in all this is that, in the medium term, we will be returning to the pre-NHS days of the 1930s with independent hospitals run by a variety of organisations outside of the NHS, with a new role for local government and with growing inequalities in the name of localism. The Big Society. Local authorities will become the provider of last resort. The rush to Foundation status brings closer the ability to borrow money, the end to the cap on the generation of income from private care and, for instance, the ability to charge for hospital accommodation. Spot the difference, if you can, between this and a private hospital.
In the longer run, it is not exaggerating to have a nightmare vision of the future in which corporate business interests will be given or get incentives to select patients, time limit care, sell top up insurance and introduce charges for some elements of care no longer provided by the NHS. This is a chilling prospect for the elderly, those with chronic illness, people with mental illness and long-term needs who are of no commercial interest to these corporations. But it will also damage the healthcare of the rest.
As Government pushes it’s competition message harder through the sham of “choice”, it will make practices compete for members (formerly known as patients) just like US health insurers. This is why practice boundaries are threatened , as , if abolished , practices and consortia will be able to compete and advertise for patients across the whole country just as private healthcare corporations and health insurers do now. 85% of GPs see the folly of abolishing boundaries and are opposed31.
So the listening exercise hasn’t changed anything worthwhile. In a democracy the order is usually consultation , legislation then implementation. Mr Lansley has attempted the complete reverse. The Government has been accused of a U-turn , but stays strangely silent in not refuting this. It can’t. If it did it would be admitting nothing much has changed ; it has judged it politically less damaging to be labelled as a U-turning Coalition knowing this might be swallowed by the public—it can then press on with it’s original intensions.
Other examples in the Government’s response ,which confirm the Bill’s original direction of travel include : (a) the outsourcing of the function of commissioning to private companies , exposing the system to a whole new raft of even less identifiable conflicts of interest ; (b) the extension of personal health budgets ; (c) promotion of the choice agenda (which promotes competition) ; (d) no mention of a reversal in the policy of allowing the NHS Commissioning Board and commissioning groups to introduce additional charges for services they decide are not part of the NHS (Clause 22 , paragraph 14s of the Bill) ; (e) retention of all the mutually reinforcing levers of a healthcare market (patient choice , competition between a plurality of providers, payment by results , and freedom for Foundation Trusts ).
It is now BMA policy that market-based policies in NHS provision should be abandoned and it continues to call for the Health and Social Care Bill to be withdrawn28.
If this Bill is not defeated in the House of Lords, we are likely to see the abolition of the NHS in England as a universal, comprehensive , publicly accountable , tax funded service , free at the point of delivery14 . If David Cameron honestly intends to avoid NHS privatisation the Bill must be amended to exclude for-profit corporate bodies from commissioning and service provision. There is no indication that he intends to do so, and thus he is clearly signalling his choice to benefit potential shareholders at the expense of patients and taxpayers. Even if amendments are introduced , they are likely to be overridden in the future. Those in Parliament voting for the end of the NHS will either be doing so deliberately for ideological reasons , or accidentally by short-sighted ignorant here-today-gone-tomorrow politicians who don’t understand the complexities and consequences of the Bill . Either way it will no longer exist, the Country will be worse off , patients will suffer and there will be no going back.
The politicians responsible will have to live with their consciences
Dr Paul Hobday MBBS FRCGP DRCOG DFSRH DPM
References
- Open letter to Mr Lansley Kent Messenger 18/2/2011
- Times Interview 25/2/2011
- Studies by The King’s Fund , LSE , OECD
- BMJ 27/1/2011 John Appleby Vol 342 p566
- Forest C , Majeed A et al BMJ 2002; 325:370-1
- Royal College of GPs 1/2/11 and Pulse 18/1/2011
- Pollock A. And Price D. “How the secretary of state for health proposes to abolish the NHS in England” BMJ 9/4/2011 Vol 342 p 800-3
- Ben Goldacre “Evidence supporting your NHS reforms ? What evidence?” Guardian 5.2.2011
- Department of Health “Working together for a strong NHS” 6.4.2011
- Ben Goldacre “NHS leaflet mixes past and present” Guardian 16.4.2011
- NHS Future Forum report Prof S.Field 13/6/11
- Lucy Reynolds : “For-profit companies will strip NHS assets under reforms” BMJ 2011;342:d3760 18/6/11 p 1365
- Health Service Journal 24/11/2005
- Portsmouth News 18/3/2006
- “The £4 billion rip-off” Red Pepper November 2006
- Matthew G. Dunnigan “Clinical Activity in the English and Scottish NHS before and after devolution 1998/9—2009/10 Awaiting publication
- “Managed competition for Medicare? Sobering lessons from the Netherlands” Okma ,Marmor and Oberlander NEJM 15/6/2011
- “The Plot against the NHS” Colin Leys and Stewart Player Merlinpress 2011
- BMA National Conference 28.6.11
- Julian Tudor Hart “The inverse care law” Lancet 27.2,1971 1(7646):405-12
- National Audit Office “The performance and management of hospital PFI contracts” NAO 2010
- Triggle N. “Fears over £65billion NHS Mortgage” BBC News 13/8/2010
www.bbc.uk/news/health-10882522
- Allyson Pollock, David Price, Moritz Liebe “Private finance initiatives during NHS austerity”
BMJ 2011 ;342: D324 19.2.2011
- Norman J. “Hard times call for new rebate on PFI deals” Financial Times 16/8/2010
38 Appleby J. Can we afford the NHS in future?
BMJ2011;343:d4321 doi:10.1136/bmj.d4321 (Published 12 July 2011)
39 Journal Royal Society Medicine July 2011
40 Polly Toynbee. Guardian 22/7/2011
41 Pulse Survey of 1000 board posts 28/9/11
42 Survey . Royal College of GPs. October 2011
43 Survey. Royal College of Psychiatrists. October 2011
44 Professor Malcolm Grant . HCSC. 18.10.11
45 BMJ 2011;343 ; D7407 19/11/11 P 1019
46 RCGP Survey January 2012
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