Seven former presidents of the Faculty of Public Health accuse the Prime Minister of ploughing ahead with an “unprecedented marketisation” of services, which poses a “major threat” to the integrity of the NHS.
David Cameron confirms that the intention is to “… drive the NHS to be a fantastic business“. How is that anything other that the privatisation of the NHS?
David Cameron faces fresh calls to abandon his NHS reforms, as a group of leading public-health experts predicts that the changes will “exacerbate inequalities” in the health of the nation.
Seven former presidents of the Faculty of Public Health accuse the Prime Minister of ploughing ahead with an “unprecedented marketisation” of services, which poses a “major threat” to the integrity of the NHS.
In a letter to Mr Cameron, the group warns: “The Bill is likely to produce a ‘patchwork quilt’ health system that will vary hugely across the country, failing to meet the diverse needs of the population and undermining the health of vulnerable, minority groups.”
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Colin Leys looks at how Scotland and Wales have rejected marketising the NHS
As expert commentators have amply shown, the coalition’s plan to privatise the NHS lacks any basis in evidence – no surprise there. What is less well recognised, and so far amazingly unmentioned in the debate, is that powerful evidence against privatisation exists on our own doorstep – namely, the fact that in Scotland and Wales the NHS is working well as a publicly provided and managed system, based on planning and democratic accountability.
Marketisation was tried, especially in Scotland, and rejected. The purchaser-provider split, which is at the root of the marketisation project, was introduced but then abandoned in both nations, and neither foundation trusts nor payment by results were introduced in either of them. PFI was used in Scotland under the first Labour government in Holyrood, and one private treatment centre for NHS patients was opened, but the SNP has since scrapped the use of PFI and taken the treatment centre into public ownership. Wales has used neither PFI nor private treatment centres. The NHS in both countries is once again planned and managed through a mix of democratically accountable central and local structures, as it was in England before the 1990s.
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Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
Nick Clegg has made a deceitful and evasive speech on the NHS. Deceitful since he suggests that all will be well and hiding the fact that the Destroy the NHS bill is intended to reduce the scope of the NHS. Evasive by avoiding any mention of privatisation or the role of private providers. It’s a feel-good speech intended to reassure people that everything is OK, that there is no need to worry, that he, Cameron and Lansley can be trusted to look after the NHS. The lying, evil sods.
We know from the experience of tuition fees and V.A.T. that Nick Clegg is a shameless liar. We know that he lies to decieve people. We know that he’s a slippery shit in the tradition of UK politicians.
Some of the lies and evasions I pulled from his speech today:
“When Beveridge first proposed a nationalised health service in 1942, he didn’t prescribe exactly how it should work.
He called for a comprehensive service to ensure every citizen can get “whatever medical treatment he requires in whatever form he requires it.”
Care, free at the point of use, based on need and not ability to pay.
No government worth its salt – certainly, no government of which I am a part – will ever jeopardise that.”
That’s a lie. The current coalition government – of which Clegg is a part – is intending to do away with a comprehensive health service free at the point of use.
“The comfort of knowing that the NHS will always be there for you.
If you’re in an accident, if you get ill, if your family need treatment.
And it will always be free. No bills, no credit cards, no worries about money when you’re worrying about your health.
That’s why I have been absolutely clear: there will be no privatisation of the NHS.”
There are a few lies here.
Firstly, GP consortia will commission services. They decide which services will be available. With cuts to spending they will cut the range of services available. There will also be some expensively ill people that will likely not have a GP. This means that the NHS will not “always be there for you”.
Secondly, perhaps not an outright lie but certainly intended to mislead and give a fase impression: “it will always be free …”. No it won’t always be free. If you need a treatment that is not provided by your local GP commissioning group, you will have to pay or go without.
Thirdly, again perhaps not an oughtright lie:“there will be no privatisation of the NHS”. There will be private provision of services not offered by a reduced NHS. There will be private providers within the NHS. It will not be wholly privatised but there will be hugely increased involvement of private providers.
Clegg continues by saying “The NHS has always benefited from a mix of providers, from the private sector, charities and social enterprises, and that should continue.”
Notice what’s missing? The public sector. Is he saying that the public sector should not continue to play a role in the NHS?
Charities and social enterprises are private providers in a sense. They certainly are not public sector.
“People want choice: over their GP, where to give birth, which hospital to use.
But providing that choice isn’t the same as allowing private companies to cherry-pick NHS services.
It’s not the same as turning this treasured public service into a competition-driven, dog-eat-dog market where the NHS is flogged off to the highest bidder.”
Choice. People don’t really want choice. They want a good service that doesn’t unduly inconvenience them e.g. having to travel to a distant hospital.
Clegg is deliberately misconstruing the argument, putting up a straw-man by saying that the NHS will not be sold off to the highest bidder. It’s about providing a restricted health service where you will have to pay – or go without – services that are not provided.
[27/5/11 edit: It’s also the first stage in the process of privatisation and transition to a private insurance-based health service on the US model.]
“I’ve heard people suggest that our reforms could lead to politicians washing their hands of our health services, because of the way the Bill is phrased.
So we need to be clearer – the Secretary of State will continue to be accountable for your health services.
This is your NHS; funded by your taxes and you have a right to know there is someone at the very top, answerable to you. With a public duty to ensure a comprehensive health service, accessible to all.”
Clegg is employing the worn-out argument that they have failed to properly explain the proposed changes. The truth is that the more people understand, the more they object.
He’s defending the Health Secretary no longer being responsible for providing the health service, arguing against what Colin Leys said ‘The bill removes the secretary of state’s responsibility to provide a national health service and doesn’t assign it to anyone else. She or he would only be charged with “promoting” it.’
Clegg suggests that this is merely phrasing when it is crucial. If it is only a matter of phrasing, then we’ll have the phrasing that the Health Secretary will provide a health service.
“opening up”…
Clegg is defending the Bill to abolish the NHS contrary to the instruction of his Spring Conference. He needs to be dumped asap.
Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
p.148~154 References in the original.
Within the BMA a strong challenge emerged to the leadership’s position of ‘critical engagement’ with the government’s plans, and a demand for outright opposition. The development of serious opposition from a large part of the medical profession, and especially from GPs , was significant, because Lansley constantly claimed to have their support.
The false case for the Health and Social Care Bill
The government’s claim that the NHS was in urgent need of further fundamental reform was also becoming more and more obviously false. During the previous ten years, while the NHS was being covertly marketized, the Labour government had raised NHS funding rapidly towards the average level of spending of the other major countries of Western Europe. Spending on the NHS still remained significantly below that of the richer EU nations, and a significant portion of the new funding was absorbed by the cost of market creation. But the extra cash also produced some important improvements. Staff levels were improved, waiting times for elective care were sharply reduced, facilities were renovated or replaced.
This was reflected in the high marks given to the NHS in the Commonwealth Fund report cited in chapter 1. And by 2010 the particular charge constantly made by the marketizers, that England lagged behing European countries in the survival rates for major killer illnesses, was ceasing to be true. Lansley repeatedly declared that a wholesale restructuring of the NHS was ‘a necessity, not an option’, and David Cameron asserted that ‘pretending that there is some “easy option” of sticking with the status quo… is a complete fiction’. But in January 2011, coinciding with the publication of the Health and Social Care Bill, a paper by the King’s Fund economist John Appleby, published in the BMJ, showed tha t the marketizers’ charge was unfounded. It turned out to rest partly on the use of European data that were not comparable with the English data (and in some cases highly unreliable), and partly on selecting static data instead of trends over time. For several of the conditions usually cited English survival rates have in fact been improving so fast over the last 30 years that if the trends continue they will overtake
European rates by 2012.
The real choice
The choice is not between change and no change. It is between handing over a public service to be developed by private enterprise in the interests of shareholders, and ensuring that it develops in the interests of the public – and as the public sees those interests, not as politicians declare them to be. To maintain that there is no capacity for improvement within public provision is empty rhetoric. What evidence is there that public servcies are incapable of change and improvement (provided they are not undermined by financial starvation or market-driven disorganization)?
Around the world there are various examples of excellent public and publicly-provided health services, and all of them need to be studied for ways to improve the NHS in England – and beginning with an examination of those that are developing within the UK itself. The national media largely ignore what occurs across our nearest borders, but what is happening there, and especially in Scotland and Wales, raise crucially important questions about the future now being charted for the NHS in England.
Looking at Scotland
Even before devolution health ministers in Westminster had been too aware of Scottish sentiment to risk pushing the internal market very far there, and the Labour-Liberal Democrat coalition governments that held office in Scotland after devolution, from 1999 to 2007, recognised that voters would not support them if they followed England’s path to a healthcare market. Scotland’s Area Health Boards remained in place, foundation trust status was not introduced, nor was payment by results. The PFI was used for three Scottish hospital-building schemes, and one Independent Sector Treatment Centre was opened at Strathco in Angus. But these measures provoked intense controversy and in 2003, responding to pressure from both doctors and the public, the coalition government ended the purchaser-provider split, restoring direct administration to the NHS in Scotland and decisively closing off the market option. Also in response to public opinion, in 2002 the Scottish Labour-Lib Dem coalition made personal care for the elderly free, instead of means-tested as in England.
The 2007 elections, however, led to the formation of a minority SNP government, and yet further departures from the market-driven policy that was being pursued in England. In 2008 hospital car parking charges – a significant deterrant for families – were abolished, except at PFI hospitals, where legal reasons prevented it; and in 2010 plans were announced to abolish prescription charges from 2011. No further PFI schemes have been undertaken. Glasgow’s biggest acute hospital is being built with public funds, the ISTC at Stracathro was taken into public ownership, and plans to outsource the management of a health centre in Lanarkshire to a private company were dropped. Out-of-hours care is publicly provided.
Perhaps most significant of all for the future, in 2009 elections were introduced for the majority of the members of Scotland’s Health Boards, beginning with two pilot schemes to be evaluated after four years. This means that in addition to professional medical judgement democratic representation, rather than individual ‘patient choice’, could become a significant element in determining the direction of future change.
In face of all this the marketizers inevitably portrey Scotland’s NHS as a failure, with the usual misuse of statistics to support their claim. For example they routinely state that Scotland’s waiting times are worse than England’s, because no element of competition has been introduced into Scotland’s. In fact an analysis of newly-consolidated data concludes that since 2005 waiting times have fallen faster in Scotland than in England. In each year since then Scotland has actually had either the second shortest or (more often) the shortest waiting times of the four nations in the UK. And over the ten years from 1999 to 2008 Scotland’s mortality rates for all causes of death declined almost exactly as fast as England’s. As Dr Matthew Dunnigan, the author of the waiting times analysis, says, the objective comparison of English health statistics with those for the three devolved nations is now a very important task.
Looking at Wales
The story in Wales has many similarities to Scotland’s. For the first eight years following devolution a Labour minority government was in office, only giving way to a Labour-Plaid Cymru coalition in 2007. But as in Scotland, even the initial Labour-led Welsh Assembly Government did not dare follow the English path. The purchaser-provider split remained, but Wales did not adopt foundation trusts or payment by results. Development remained based on collaboration and planning, rather than on a market system with legally enforcable contracts and all the tensions and extra administrative costs involved.
And after 2007, under the Labour-Plaid coalition, the purchaser-provider split was dropped. In 2009 a major reform resulted in the formation of just seven integrated Local Health Boards to plan and operate the NHS in Wales. These are very like the Area Health Boards in Scotland, but also have overall responsibility for all aspects of health, including public health, with a strong emphasis on linking health and social care.
The Local Health Boards in Wales are not elected but they must have members representing local primary care, community care, public health, local government and voluntary organizations, as well as lay members. In one Local Health Board (Powys) the purchaser-provider split was abolished earlier and the Board was integrated with primary care and community health service providers. Other Boards are set to follow suit – exactly the opposite direction of change from that taken in England, where even community health services have been forced into the marketplace.
Wales also declined to use the PFI for hospital-building, led the way (in 2007) in abolishing prescription charges, abolished hospital parking charges, and dealt with the vexed issue of means-tested personal care for the elderly by widening the definition of what is considered nursing care (and therefore free), and by setting a flat-rate contribution to the cost of personal care throughout the whole country.
Considerations for England
We need to ask ourselves why Scotland and Wales opted to keep the NHS as a public service, and even extend the principle of free acess. Longstanding Scottish and Welsh cultural traditions are certainly important, especially a deeply-embedded commitment to social democracy in public life, and in the medical profession, which politicians of all parties have to respect. But another key reason is cost. Next to education health is by far the most important and expensive devolved publis service. Even before the financial crisis politicians of all parties in Scotland and Wales realised that if they followed the English route, and allowed the costs of operating a market to start soaking up ten per cent or more of the health budget, health services would be liable to deteriorate, with dire political consequences for themselves.
They know that the public spending cuts imposed by the government in Westminster will hit Scottish and Welsh health services. But they also know that the effects will be smaller that they would have been had they opted for a market, and that whatever they have to do will have a legitimate foundation in public opinion, which remains at the base of decison-making about the NHS in both countries. And when the crisis has passed they will still have a public health service, not a three-tiered healthcare market and a low-risk playground for healthcare corporations and ‘doctorpreneurs’.
Scotland and Wales don’t exhaust the alternatives for the future in England. Other good models of publically-provided health services exist and deserve study. But the successful evolution of the NHS in the rest of the UK shows that Cameron’s assertion that ‘we can’t afford not to modernise’ – meaning that we have no alternative but to accept the abolition of the NHS as a public service – is pure bluster. It has no foundation in evidence and serves no interest except that of the private health industry. In the parts of the UK that the plot against the NHS couldn’t reach, people see through it. They know that good health care for all means excluding profit-making, and have shown that with sufficient public backing that principle can prevail. We need to insist that in England too the NHS is not for selling.
Selected excerpts from ‘The Plot Against the NHS’ by Colin Leys and Stewart Player. Chapter One is available here. I highly recommend this book available from Merlin Press for £10.
I got my copy yesterday so I have yet to complete it. The book identifies intense lobbying by commercial interests resulting in the privatisation of ancilliary NHS services under Thatcher, covert privatisation of the NHS under Blair’s New Labour administration and Andrew Lansley’s overt privatisation under the current Conservative and Liberal-Democrat coalition government. It draws a picture of the private sector unable to compete with the NHS in terms of cost or quality and the private sector being given excessive, hugely favourable terms. Patricia Hewitt, Alan Milburn and John Reid are identified as covert privateers ‘marketers’ under the Blair administration.
p51
By late 2008 the crisis was at it’s height. Lehmann Brothers was history, Northern Rock had been nationalized along with Lloyds and the Royal Bank of Scotland, and the government’s debt was on course to reach 70 per cent of national income, up from around 40 per cent for most of the decade. In this situation it was obvious that public spending was going to suffer. How would this affect the NHS?
According to the Department of Health, the management consultants McKinsley (where Dr Dash was by now a partner in the company’s London office) were instructed in February 2009 ‘to provide advice on how commissioners might achieve world class NHS productivity to inform the second year of the world class commissioning assurance system and future commissioner development. The advice from McKinsley … was provided in March 2009.’ But the advice McKinsley gave actually tells a different story.
We don’t know what assumptions they were told to make but it looks as if they were told or at least encouraged to assume that NHS spending would remain constant for the next five years, and asked how productivity could be increased to cope with the rise in demand over that time. Their conclusion was that in order to find enough savings to meet the rising cost of providing health care over those years the NHS might have to shed ten per cent of it’s staff. When the press got hold of the report in September 2009 there was a furious reaction from the NHS workforce.
Health ministers then said that the report had been rejected, and even then it had been commissioned without their authority.
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p54
In October 2010 the coalition government announced that it would continue to raise NHS spending in real terms (based on the general consumer price index) over the next four years – the figure actually claimed was an annual rise of 0.1 per cent. As a result most people outside the NHS assumed that the cuts would now stop. But the reality was different. For one thing, the NHS was told to transfer £2.1 billion to local authorities over the next five years as part of a drive to move patients out of hospitals and into more ‘cost-effective’ social or community care. So the NHS budget was actually being cut. And the NHS’s costs (for drugs, equipment, electricity, etc) would go on rising faster than the general cost of living, so that even if its budget stayed more or less constant it would soon be too small to cover all the bills.
On top of this, people’s healthcare needs (or ‘patient demand’, as today’s policy-makers call patients’ needs) would also go on rising as people got older, or more obese, or more depressed – and as more of them became unemployed. The economic crisis was thus also a healthcare crisis, in which drastic measures could be presented as being unavoidable, measures of ‘last-resort’ – even if they implied the end of a high-quality health service equally available to all.
Which was pretty much what the new Secretary of State for Health, Andrew Lansley, decided to do, with proposals for yet another NHS reorganization – a reorganization not only un-mentioned in the election campaign, but one that flatly contradicted David Cameron’s pledge not to undertake any more ‘top-down reorganizations’ in the NHS. Everyone noticed, of course: but the coalition’s argument that the financial crisis meant that all previous bets were off proved effective – even if at first most people couldn’t quite see what Lansley was driving at. All comentators agreed in calling his proposals the most important changes in the NHS since it was set up – but what exactly did the changes mean? And were they really so different from what had been covertly planned for ten years or more under New Labour?
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p68
By the time of the 2010 election a fairly clear picture of what the future NHS market would be like had emerged amoung health policy insiders. Influenced by a decade of exposure to US policy advice, and especially by the link with Kaiser Permanente, they envisaged an NHS that was already much closer to being a kitemark attached to a wide variety of provider organizations and systems than people outside the policy-making circle realized.
They imagined a radically reduced NHS hospital sector, with the surviving NHS foundation trusts focused intently on financial success. They envisaged the bulk of outpatient care being transferred out of hospitals into local, cheaper settings, which would be privately built and owned (as so many NHS hospitals already were, through PFI), or jointly owned with ‘entrepreneurial’ clinicians. They envisaged a growing number of the remaining NHS hospitals being run by private companies. They imagined specialist clinicians becoming increasingly self-employed, rather than working on a salary for a single foundation trust, and selling their services to a mix of public and private organizations.
They expected a growing proportion of patients with chronic illnesses to have fixed budgets for their care, and they accepted that top-ups, for which insurance companies would provide insurance plans, would become a normal form of co-payment, as they already were for some life-prolonging cancer drugs. They expected PCTs to be using private healthcare corporations to help them commission services in a more sophisticated way, or doing it for them, and so driving foundation trusts to become more focused on economy and driving more work to private providers. Fundamentally, they anticipated a replication of many of the structures and values of US managed care.
No one who was familiar with this imagined future could have been surprised by the contents of Lansley’s White Paper of July 2010, or the Health and Social Care Bill of January 2011. The only people likely to be surprised were the public, with whom the marketizers had chosen not to share their vision.
