In 2010, the National Health Service fell to its least importance as an issue among voters since 1986. Now it’s back at the top of the political agenda. Just as it was in 1999. Why? Because, after four and half years of the Conservative-led coalition, healthcare is in crisis. Markets haven’t worked, inspection hasn’t worked, demand management has failed, morale is at an all-time low and workforce planning is botched. The major consequences of the 2012 Health Social Care Act has been that healthcare in England is viewed as a business rather than a service.
The key political challenge for many is how to persuade politicians that they are wrong to believe health should be viewed in this way, and to explain how we can sensibly reinstate the fundamentals of the NHS that are being dismantled in England – fundamentals that elsewhere in the United Kingdom remain intact and widely supported.
The NHS is one of the most cost-effective, highest quality and most equitable healthcare services in the world. Nevertheless, it now stands on the brink of extinction.
Citizens of countries which have mainly private sector healthcare systems – as we soon will have if the coalition is allowed to complete its reforms – regard the NHS as a jewel beyond price: safe, high-quality care available to all no matter how poor. This is the most civilised accomplishment the British ever achieved. There is even a nationwide activist movement in the United States devoted to trying to introduce an NHS-style model in their country. And yet our own Government is itching to convert our NHS from a public service to a set of business opportunities for US-based transnational insurance and health provider corporations.
The Coalition’s Health and Social Care Act is leading to the rapid and unwanted expansion of large commercial companies in the NHS. It will denationalise healthcare through the initial “hand-washing” Clause One of the legislation which divests government responsibility for service coverage to competitive markets controlled by private sector-dominated quangos.
GPs have been herded en masse into clinical commissioning groups (CCGs), statutory insurance schemes which will implement the transition from the guarantee of universal care to limited financial care allowances for each individual. They are presiding over the parallel competitive markets of tendering and Any Qualified Provider (AQP) which the coalition and its private sector advisors intend will privatise hospital care in England.
GPs lack the necessary legal and finance training to discharge these responsibilities, but have been given them with a cynical accompanying commentary in the White Paper
Equity and Excellence, about “GP empowerment”, so that patients and the general public will blame the withdrawal of NHS services and the fall in quality of those privatised on doctors rather than the Conservative Party.
The Government is now trying to make GPs relinquish their Minimum Practice Income Guarantee (MPIG), which is what ensures the financial stability and continuity of family practices. It is considered “anti-competitive” by privatisation advocates, in that a competitive market demands some providers go out of business so others can easily enter the market. The Government has decreed that GP practices are to be made vulnerable to insolvency and closure, so corporate providers can replace them. Therefore, the MPIG must go. In other words, the Government has decided to replicate the example of the Camden Road GP practice, which was tendered out, and the incumbent GPs’ bid lost, so the contract went to an American insurance company which allegedly and illegally transferred it to a corporate GP service provider after two years. This company then decided it wasn’t a profitable enough business, and shut it down, leaving 4,700 people without access to GP and referral services. Many of them were unable to find any local alternative. Observers saw this as a cautionary tale, but apparently Health Secretary Jeremy Hunt finds it so admirable that he is removing the protection which stops similar things happening throughout the country.
The coalition has no electoral mandate for what it has already done to the NHS, let alone what they it is now trying to do. We are witnessing an attempt to make an end of the NHS as a publicly provided, publicly financed body, so as to please private companies. In this sort of health service, the chronically and terminally ill, the mentally ill, those from poorer socio-economic groups, and the elderly are likely to lose out. Commercial providers are most interested in affluent people who are in good general health whom they can talk into having expensive elective procedures. It is hard to turn a profit from caring for seriously ill people, so their care will be left to the increasingly cash-starved CCGs whose funding will be drained by “money following patients”, as insurance companies arrange for their insurees to move their personal health budgets from their CCG to their insurer. As healthy people take their budgets out, while ill – hence uninsurable – people stay and require care, referral spending will have to be reduced across the CCG as the budgetary pool it uses to buy care shrinks. The contraction in service coverage and content that will be forced on CCGs will encourage more take-up of private health insurance followed by more money following patients out of CCGs into insurance companies. This vicious circle will quickly reduce the service CCGs can offer to almost nothing.
The Government’s dismantling of the National Health Service has a genealogy running from Margaret Thatcher through the years of Tony Blair to David Cameron’s coalition. The last Labour Government laid the essential groundwork for undermining the NHS. Market structures, foundation trusts, GP consortia and the introduction of private corporations into commissioning were all products of the ill-conceived Labour vision of “public service reform” sponsored by private sector interests.
For the past two decades, the leaders of all three main political parties are wedded to the concept of marketisation of healthcare. Do our gullible leaders really believe the “chosen” private healthcare firms will treat all patients fairly, and not just select those based on the criteria of how much profit will be returned? The commissioning system makes it easy for private providers to cherry-pick from the tasks they bid to do so as to ensure they maximise their income from the NHS while minimising their costs. This has the effect of maximising their profits overall. From the perspective of both patients and taxpayers, this bias is highly undesirable – a recipe for overcharging, overtreatment and corner-cutting on safety.
These problems can be acceptably controlled by tight regulation, but unfortunately we have a Government wedded to the lightest of regulation because this “keeps costs down for business”. Ministers ignore the risks to the public of failing to regulate healthcare providers which have an incentive to run unsafe services because the money not spent on ensuring safety contributes directly to their profits. The real interest in “choice” is not among patients, for whom we could simply have complete countrywide choice of referral care which existed before market reforms started. Those who are for the kind of choice which these reforms will allow are providers, who will soon be able to decline to deal with cases which may be expensive to treat, usually those patients with complex or multiple conditions. They are the patients who need the NHS most, and yet they will be forced to rely on the ever more cash-strapped CCGs.
It’s time we dropped the unfounded stereotype established by intensive neoliberal propaganda that “private equals best”. The NHS is rated as one of the finest health services in the world, according to the latest Commonwealth Fund study. It is by no means perfect, but of the 11 countries surveyed, the United Kingdom came out on top, with the fastest access to GPs, the fewest medical errors and the best co-ordinated care.
The obvious area to cut unnecessary bureaucracy is the market apparatus of commissioning and competition regulation which benefits only private sector providers, not patients, and wastes a great deal of precious time and money. The marketisation of the NHS has seen the proportion of the budget devoted to administration rise from 5 per cent to 14 per cent, so very worthwhile savings could be made by rationalising service provision according to medical needs rather than market forces. We could start by axing Monitor, a regulator paid by the public sector and run by representatives of the private sector, which is engaged in two tasks: privatising NHS hospitals and ensuring the CCG system does not disadvantage the private sector.
If the Department of Health and the management consultants it put in the driving seat had not addressed every problem in the NHS as an excuse to recommend more private sector involvement, we might be much further forward in fixing the NHS’s real problems, such as the internal hostility to staff who alert others to dangerous problems. Scotland and Wales have already rolled back market reforms, and been rewarded by an immediate drop in costs and improvement in outcomes. It is clearly in the country’s interest for England to follow their example, but instead our Government would prefer to conclude more contracts with the likes of G4S, which already manages facilities for 210 hospitals and health centres, as well as running ambulance services.
Far from “private being best” in service provision, a little consideration of the nature of the endeavours of private and public sectors shows that private sector efficiency may not be at all to the advantage of either payers for services or users of services provided. For while the public sector seeks to maximise quality and coverage of needed services, the private sector aims to provide services in order to maximise profits.
For public limited companies, this is more than an opportunity; it is the duty of the directors. Thus the private sector faces irresistible forces against maximising quality because company law forces it to choose profit over quality, requiring systematic satisficing on quality in order to maximise profit. (Satisficing is producing the minimum quality that the company can still get paid for and not get taken to court over.)
Since the Government is intent on forcing for-profit providers into the NHS, the only way for the public sector to ensure a safe healthcare system is to inspect all activities where risks might arise, and inspect them rigorously, thoroughly, frequently and always unannounced. The cost of this level of regulation is so high that it adds substantial extra cost to the already more expensive market system, but without it, the level of quality to which private providers will sink in order to maximise their profits will soon pose significant threats to patients. We saw this story play out at the private equity-owned Winterbourne View and its sister homes, where cost economies resulted in abuse of vulnerable people by unsuitable staff, some of whom have been jailed for their crimes against residents.
If we don’t want tragedy upon tragedy, we must stop organising our health services through arrangements such as these which have endemic quality problems due to perverse incentives towards satisficing on quality in a lax regulatory environment that enables rank exploitation of patients.
The terrible state of the healthcare system in the US reinforces the point that the privatisation of state-funded healthcare delivery is not something that is welcome in England except by big business and those paid to expedite its entry to the NHS. The US government spends more on healthcare than any other nation, close to $2.4 trillion a year. But even though that is 150-200 per cent of the amount that other developed countries pay, on top of that most US citizens also have to buy health insurance in order to have some chance of accessing appropriate care if they fall ill. Only forces veterans and the extremely poor access free care, and only the veterans enjoy care of a standard usual in the NHS. Extraordinarily, given the disproportionate amount it spends, the US’s health indicators are worse than those of all other developed countries, and indeed worse than those of many middle-income countries.
In the United States, reliance on private health insurance sees the rich treated and the poor not – and paying for medical care at US market rates