Thursday, September 08, 2011

Ten things you'll miss when the NHS has been eviscerated

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Last night the Health and Social Care bill passed its third reading in the House of Commons owing to the natural majority of the coalition government. It passed by a majority of 65 votes (316 to 251) after four Lib Dems voted against it and ten abstained.

The report stage debate, which preceded the final vote, epitomised all that is now worst about our democratic system.

Over 1,000 amendments were added at the eleventh hour, in ways that couldn't possibly be challenged. Ninety minutes of the precious debating time was given over to consideration of an abortion provision tabled by Nadine Dorries. And, if you watched it on TV, you would have seen very few MPs in the chamber, as legislation to radically alter a precious 63 year old institution was waved through in what had become a formality.

Still time

The bill is not law yet ... it still has to pass through the House of Lords ... although many changes had already taken place in the NHS structure before a word of the bill had been scrutinised by the Commons. Such is the contempt which the present administration has for due process.

There is a campaign to persuade members of the Lords to challenge and scrutinise the legislation. This website will give you the name of a Peer to 'adopt', and you're then encouraged to write to them.

Peers don't have constituencies and are not elected, so they don't have to fear the ballot box. This is why people don't often lobby them direct. Conversely, it's hoped that the novelty of a mass campaign appealing to the Peers' sense of independence and traditional constitutional role, will embolden their lordships to give the government a bloody nose.

Any popular campaign relies on people understanding why it is important to act. In this case the cause has not been helped by certain of the mass media (the BBC in particular) failing to challenge the issues effectively.

I have asked people to reach beyond social media networks and talk to their families, friends and coworkers about the issues, and to get them involved in lobbying the Lords. However, people have rightly pointed out that that is difficult to do if people can't readily understand what the changes will mean in personal terms if they go through.

So here are some consequences to discuss with your friends.

Ten things you'll miss

  1. When you go to see your GP and they say you don't need to see a consultant or should take such and such a drug you will no longer be sure whether that decision is because it is best for you or because the GP has their eyes on a new Mercedes. Giving groups of GPs (now called Clinical Commissioning Groups) control of £80,000,000,000 of the NHS budget means just that.
  2. When it takes longer to get an appointment with the GP it is likely to be because they are spending less time doing medicine and more time in meetings with staff from companies like KPMG who are making their commissioning plans for the board to rubber stamp. Commissioning is a complex process. Don't imagine it can be achieved in a few minutes round a desk by a bunch of GPs in their coffee break. The health consulting industry is poised to move in. And how many GPs will know enough to challenge the advice of the experts, with all those impressive charts they'll have?
  3. If you want to challenge those plans then you'll find that the Clinical Commissioning Group that your practice is part of has decided that the meetings about such important things must happen in private. You'll find local politicians hamstrung because of the complexity of the system and the relationships between bodies.Even the experts haven't figured out yet how it will all work.
  4. If your GP does say you need to see a consultant then you'll find that there's an awfully long waiting list because your local hospital will be selling as much as 50% of its capacity to private patients. This is something that existing NHS hospitals will need to do just to balance the books, especially as the government starts rationing public money for the system, year on year.
  5. If your care requires collaboration then you'll find it can't happen because parts of the care path are being run by private companies who use different systems and, besides, planning services in that way could be seen as anti-competitive. The experts are still arguing whether the system known as 'Any Qualified Provider' means decisions about working together can be challenged using European Competition Law. What is certain is that GPs won't know, and that the big money private providers lining up to exploit the uncertainty have pockets deep enough to afford the very best lawyers to challenge every commissioning decision they don't like.
  6. If you have a specialist need then you'll find you can no longer use your local hospital because your doctor's commissioning group has contracted each condition to different private services which, for efficiency, serve large areas and are located 50 miles away. Note that some of the first services to be contracted out in this way will be things like maternity services, because the cost profile of these is very attractive to private providers. Your local NHS hospital will be left with the complex, chronic, expensive cases. It will have to take on private cases itself in order to make ends meet.
  7. In the longer term you'll find a system in which doctors and nurses become increasingly scarce and are not keeping their skills up to date, because the system of teaching hospitals has broken down and the private providers don't want to spend profits on training junior doctors. The Strategic Health Authorities who currently manage the commissioning and provision of training and ongoing development will be abolished in a couple of years and the health bill currently has no plan in it to replace that function. Health Education England (as mentioned by one of those White Papers that came out like confetti last autumn) is still no more than just a name.
  8. The question of which practice you register with will suddenly be a lot more crucial, as this will determine which Clinical Commissioning Group will be paying for any care you need. Health will no longer be planned on the basis of the needs of a locality, but on the basis of the business plan for that collection of practices. Two adjacent surgeries may have very different budgetary priorities and it is quite possible this may actually be used in a deliberate way. For instance, a Clinical Commissioning Group (CCG) whose patients are all young middle class earning professionals without long term illnesses will have a much different cost base than one dealing with patients with chronic illnesses. PCTs currently balance that up by something called 'risk pooling'. Most PCTs serve populations of 150-300,000 people. Within that there will be an average mix of all needs .. so the budget can withstand patients who suddenly need £70,000 on a heart transplant or long term kidney dialysis. If the balance is disturbed then the services with young and fit patients will pocket their profits whilst those serving less well patients will have to ration or go bust. Commissioning Groups WILL be able to go bust, like hospitals. So, if your GP says their list is full but the waiting room looks empty you'll just have to wonder...
  9. We don't know how the system will stand up when there is an epidemic or other health crisis because the whole system of public health is about to be reorganised on new lines and the SHAs and PCTs who formerly planned for and coordinated the system's response to crises are already being taken apart and disbanded.
  10. And when all of this goes wrong, you are also likely to find that the Secretary of State for Health will step back and claim that his hands are tied and that it's all now out of his control, because the traditional accountability vested in him for the last 63 years has been turned into something that armies of lawyers and politicians are still arguing over. Yesterday, in Parliament, the government and opposition had two diametrically opposed legal opinions on this point, which is the first clause in the legislation.

And just a reminder

The NHS wasn't broken in the first place. In fact, various studies indicate that the present system has been on an all time high in terms of public approval, and that Britain's health service delivers top class results for less percentage of national GDP than other systems.

The case for change was not backed by any evidence. Although a system this large and complex (employing 1.4 million staff) could always be improved around the edges, it was fundamentally healthy.

There is now only one chance left to prevent the government's wrecking bill from becoming law, and that is to persuade the House of Lords to show its teeth. The degree to which they do that will depend on how much you can persuade your friends and family to pester them about it.

When the NHS is gone, it's gone. These changes will not be able to be reversed.

The majority of Britons have been born and grew up under a health service that was run for the public good rather than for profit, and which was strategically managed in all our interests. Mostly we take it for granted that it is there when we need it. The rest of the time people probably don't think about it that much.

One day, when you need it, you may discover (too late) that these changes really were as serious as I've said.

In the meantime, have you noticed the sudden glut of advertisements for private health insurance?

37 comments:

Alex said...

I agree with you stance regarding the pointlessness of these changes, but, I find your attitude towards Dr's comes across as highly derogatory.
I work within the NHS and have been actively affected by these changes already, because as you said, they have been well under way for some time already. The Dr's are as unhappy about it as the patient's. The majority of GP's won't have much to do with the management and funding side, within the consortia I have experience of they have highlighted certain GPs who will deal with seperate bits dependant on interest and skillset. Some are remaining, quite firmly I might add, pure clinicians. The suggestion that treatment would be impacted by a desire to get a mercedes is quite crash in my mind.
I have seen a number of positive changes happen by professionals trying to make the most of all that is going on around them, changes that have benefited patients considerably: a good example being district nursing services in 1 area being open 8am-8pm 7 days a week instead of the original 9-5 7 days a week.

Christine Burns said...

Alex, read carefully what I have written. I am not ascribing motives to GPs or saying that they will do things, but that these are things that people will suspect them of doing because this is going to be a system riven with the potential for conflicts of interest.

richard.blogger said...

Great list. Here are some points to reinforce what you have said.

1) The figure of £80bn is what PCTs spend, CCG will spend £60bn. Where has the other £20bn gone? Its going to the new super quango, the National Commissioning Board who will take over the specialist commissioning that SHAs do, but will also commission GPs, opticians, dentists and pharmacies, ie a centralised organisation will do the commissioning that before was done by local PCTs. When Tories tell you their bill is all about "devolution" and "decision making closer to the patient" they are wrong, there will be £20bn of commissioning that will be carried out by an unaccountable quango.

2) The National Commissioning Board will be very powerful and it will effectively replace the Department of Health and the Secretary of State (when he has less work, will he have his pay cut? I think not) and SHAs. We know who will be the Chief Exec (Sir David Nicholson, the current most senior civil servant in the Dept of Health) but who else will be on the board? We do not know. The board will be extremely powerful with very little democratic oversight (accountable just once a year in Parliament). It is possible that Lansley will fill the board with privatisers who will then give guidelines on how GPs should commission (ie private companies). There will be bugger all that we can do about who Lansley appoints to the board.

3) Training is very worrying, and I haven't yet heard a single good word about it. At my local hospital 1/4 of Dr pay is from the SHA through their training budget. This is because junior Drs are paid a salary as they are trained, and the consultants who train them are treating fewer patients so the hospital is paid to fill the gap with another consultant. This money is under threat. The last I heard, the govt said they would pay for training until Drs are registered. However, medicine requires constant training even for fully qualified Drs, so this extra training will have to be funded by the hospital.

4) Hospitals are being cut. The tariff (that pays for about half of hospitals' work) has been cut by 1.5% this year. No "real terms increases" for hospitals! Hospitals have had to shoulder extra expenses - the single sex diktat came with no money attached, so hospitals have had to find the cash to convert wards or they will suffer large fines. There is now a long list of "never events" that will result in a fine. And in the future there is the prospect of hospitals having to pay for training and to pay a levy (possibly a %age of their income) for the risk pooling that you mention above that the government currently provides.

Please people, if you are going to be sick, be sick right now. We are months away from a crisis somewhere in the NHS, just hope that it is not where you live.

Christine Burns said...

Thanks for that Richard.

On your point (1) I think you'll find that even more of the actual big commissioning decisions will be made by the NHSCB or its outposts (the four SHA Clusters) in the early days. Looking between the lines of the circulars issued by Sir David, I think he is too obsessed with maintaining grip to let much go. And there's a distinction between the jobs of designing pathways / services, procuring multi million pound contracts with providers and rationing who is allowed to have a referral. CCGs will be allowed to tinker and produce the little examples of innovation to feed to the gullible media, whilst the big stuff is carved up by the people in suits purchasing from other people in suits. The system ensures any blame goes to the people in the white coats.

On your second point, the model so far seems to be to recruit via the time honoured principle of tapping people on the shoulder. How many of the appointments announced so far have involved advertising, shortlisting and interview?

Christine

richard.blogger said...

Christine,

"even more of the actual big commissioning decisions will be made by the NHSCB or its outposts"

This is the bizarre thing, isn't it. The Government is pushing "patient choice" and AQP to voters which is micro-commissioning, yet on the other hand we have the NHSCB doing the real stuff. I think this is a significant point and needs wider publicity. The fact is, what we are being promised ("no decision about me without me") cannot be delivered if the big decisions are being done by the new quango. (FYI the NHSCB "outposts" cover populations of up to 15 million, hardly local).

"How many of the appointments..."

We have the Future Forum as a model here. The FF was supposed to be temporary, but now it appears to have become some kind of government approval committee on a semi-permanent basis. How did people get appointed to that?

Christine Burns said...

If I named names I WOULD get into trouble. However, the nepotism is astounding. Still, that seems to be very much in keeping with the wider political zeitgeist. We have entered a world where democracy is just a word, not a practice.

David Hickson said...

Christine

The points you make are fair, although they appear a little cynical and focussed on the downside.


My reason for opposing the revisions that are being put into effect, and will be rubber-stamped by the passing of the Bill, relates to the fundamental principles of the NHS, which are not touched by any of your points.

The NHS is a system of healthcare for the Nation paid for through taxation, universally available and owned by us all. The actions of the Department of Health, endorsed by the Bill, remove the mechanisms that keep this in place for England. They do not directly remove it, they simply clear the way for personal greed, on the part of all players (including patients), to undermine it.

The Bill makes it clear that something called NHS provision will remain, but only as a part of publicly managed healthcare in England. Patients will be encouraged to demand a higher standard of service than the NHS can afford. They will be offered the choice of paying to achieve the standards that they wish to see.


As service provision inevitably needs to change over time, these needs will not be met by new public providers but by those from the private and third sector. Those who provide some NHS services (e.g. Acute Foundation Trusts) will presumably be allowed to retain the NHS badge, as it will doubtless be made available for use by others in the same position. For providers, the essential assurance that "NHS = Publicly owned" will be lost.


The points you make all refer to quality of service. Standards will not necessarily fall as you suggest. The fact that payment from patients will now be available to subsidise a proportionately diminishing contribution from the public purse may well be seen to deliver the improved outcomes and higher standards of service which are said to be the purpose of the reforms.


That is why I oppose these reforms, because they will cause England to opt-out from the NHS as the universal system of publicly managed healthcare provision. It cannot work in this diminished role, although reports will conflate the two.

"Public Healthcare - England" may continue to include what may be misleading described as elements of the NHS, but it will not be the NHS. We must take greater care in understanding the difference between the two.

Christine Burns said...

David,

You say that I have focussed cynically on the downside of the Health Bill's effects. My aim was to explain those downside issues because few in the mainstream are articulating them clearly in ways that ordinary people can understand.

That's not to say that I don't expect people will see positives.

For instance, one group of service users that I know a great deal about has been pleading for greater diversity in provision for years, and will probably welcome the choice that AQP brings them, along with the effects of national level commissioning for their specialist needs.

You also only have to look at the open market in optician and dental services to see that competition for discretionary spending on well defined mass market health needs can produce attractive services.

I don't doubt that a similar transformation will occur in some of the need areas with well-defined episodes of care ... but only on the same terms. I.e. That people are persuaded to pay for something they were previously able to access in a basic form for free.

And try finding an NHS dentist these days. What starts as an optional premium service can soon become the default necessity for all but the poorest.

Furthermore, to maintain that analogy, consider the way high street opticians have hived off just the part they want, which is a route to selling us all expensive frames every couple of years. If you have a chronic eye condition then they have nothing to offer. It's off to the NHS again to get your cataracts removed.

Those of us with enough money could always make choices within the limits of our bank account or private health insurance. I've used private hospitals quite a lot for elective treatments, and I like a hospital bed where the lunch menu includes a wine list.

What will change is that the paying option becomes less discretionary and more the norm, whilst services for those who can't afford that option become more and more scarce.

What won't change is that healthcare insurance won't cover this kind of care for pre-existing or chronic conditions. As I approach retirement age, I personally find that rather frightening.

As you say, we move away from the principle of a universal national health system which is free at the point of need.

David Hickson said...

I believe that it is proponents of the reforms who would describe your comments as cynical and negative, because they would appear as such from their perspective.

You have rightly highlighted difficulties that those without the means to exercise consumer power may suffer. It is however fair to say that such difficulties could be suffered by all if the right to exercise consumer power continued to be denied - we cannot avoid this argument.


I oppose the reforms because it is our right to exercise power as citizens, in declaring that we wish to have a National Health Service funded by the taxes we pay, that has not been properly tested.

If "Public Healthcare - England" is to be established, outside the terms of the NHS (albeit with some elements of the NHS subsumed within it) one could argue that the people of England should be provided with an opportunity to express their will through a referendum, due to the radical and constitutional nature of such a reform.

The fact that, at successive recent general elections, we have returned an overwhelming majority of MPs who represent parties (the three largest represented in the Commons) committed to this type of reform is however a strong argument against the need for such a referendum.


It is the reduction of citizens to consumers which lies at the heart of this. The word "stakeholder" (which was once being used) expresses this very well, as the power that can be exercised is proportionate to the size of the stake held.

The power of a consumer is that of the money they have available to spend.

You are right to highlight effects on "minor consumer stakeholders" that are inevitable. It is however because "our NHS" simply cannot entertain any such nonsense, as a point of principle, that the proposals for "Public Healthcare - England" must be opposed.


(We are essentially in agreement - I aim to offer a clear and powerful focus for our shared opposition to the reforms.)

Oliver Gill said...

I can't understand how this Bill is moving steadilly ahead Christine. I have had steady treatment for thyroid cancer for pas 20+ months. When I began treatment Jan '10 I was astounded by the level of cooperation in my local hospital. People have started to mock the NHS here and there, but it's worth reminding them that NHS does teach ALL doctors, and the treatment I received from my PCT was so well integrated that comparing it to friends on a cancer forum who 'went' private, it was clear that I had a 'package' that spotlighted all the failings of the private sector.
It's because consultants at my hospital(note the my)are part of teams treating & teaching, that it was such a great place to get well.
But as the months have passed things are changing. It's almost impossible to get something called Thyrogen(artificial thyroxine) for use during certain scans or radiation treatments(RAI). It would appear having scan is also going to be rationed, and TC is a condition that is only supressed so scans & bloods are crucial for rest of life.
I suppose what I'm saying, what we're all saying is 'don't fix it if it ain't broke', and I know the money, the cost will escalate for the oncoming abandonment of Cooperation.

Christine Burns said...

Oliver, thank you so much for your contribution. Oddly enough I was only listening to an item about Thyroid Cancer on Woman's Hour this week. My best wishes for your health.

Your point highlights that so much of what is said about these changes comes from the mouths of those who haven't experienced the system working like this.

Health isn't a commodity. Quality teamwork and learning can't just be 'bought in'. The NHS is more than the sum of its parts .. a point that accountants and private sector investors will never understand.

Oliver Gill said...

Thanks Christine, and also for the news about Womans Hour(a friend on one of the forums has also clocked it, so I shall iplayer it). Two broad brush strokes you highlight are the 'asset stripping' of talent from the NHS in the wake of creeping privatisation(the health pro plunder that will escalate), and the sense I gather that so many people who already receive meds via NHS, or most certainly will in the future, don't understand the grave moves underway. The sleepwalk, despite the valliant campaigning, is strange to behold.

Come on people - wake up.

All the best Oliver.

Jobs on a Farm said...

Definitely the reforms that are making health systems in UK and in many parts of the world are a mess. Now patients are seen as customers, not as people who need of wisdom and knowledge of a doctor to cure their diseases. And worst of all, doctors are losing their professional ethics to make things that are best for the company health or hospital that the patient.

Gareth Stephenson said...

I fully agree with your comment but am not sure it is helpful to suggest that GP car purchases and commissioning budgets are interchangeable. I also know GPs who think the new proposals are desirable in some ways, notwithstanding the obvious flaws. In my blog I have sugggested two 'patches' which would make the bill more likely to help the NHS and more likely to be acceptable to those within it. I would be very interested to know your views on it! http://bigsocietygreenpaper.blogspot.com/2012/02/memo-to-andrew-lansley.html

Anonymous said...

Point No. 1

The PM said patients will have more choice therefore if a patient wishes to see a consultant s/he will be able insist they are sent to a consultant of their own choice.

Or

Could this mean that there will be discrimination against patient on grounds of criteria such as age, etc.

Christine Burns said...

Thanks for your comment Gareth. I'm making it easier for people to read it by linking here

However, in response, two points:

Firstly the comment about buying new cars was not to say that GPs would actually be swayed in this way, but to emphasise the motives that their patients might attribute. This isn't about actions but about loss of trust.

Second, although I've read your post I don't think the NHS is served by heaping complexity on complexity. The fact is that the system was already performing exceptionally well before the coalition took an axe to it. Their assertion was that the NHS needed the change they wanted to bring about, but the evidence says the opposite.

The bill could be abandoned here and the NHS would survive. The contraction of PCTs and SHAs into clusters was a plan that Labour had already prepared and it arguably delivers a slightly smaller administration, at the cost of far less local decision making and accountability. However, one could live with that.

And it is false to claim that the NHS Commissioning Board offers something better. It, too, is a layered bureaucracy. However, instead of being accountable to local stakeholders it imposes an iron grip on the organisations that would replace PCTs. The government talks about the importance of localism, yet the NHS CB takes it away, with local tendrils of the commissioning board breathing down the necks of Clinical Commissioning Groups over every decision they make.

The only autonomy for CCGs will be the right to take the blame locally when things go wrong, as they will

Andrew Cooper said...

This is really excellent. I'd like to see a reasoned rebuttal of each of your points by someone who is in favour of the changes. At present best that the the Conservative and Libdem politicians who back the bill seem to be able to muster in their defence is 'we're right/they're wrong' attacks on the Royal Colleges and the BMA and ad-hominems.

Re. the Mercedes point, it seems to me to be that the best designed management and economic systems tend to fail mostly due to pure and simple greed. It certainly applies to communism and more and more people, even on the right, are arguing that the efficient markets hypothesis, which underpins market driven reforms, is fine in theory but takes no account of how people actually behave.

This isn't about GPs, it's about the human condition. The idea that KPMG and McKinsey - firms whose partners charge thousands a day for their services - will be responsible for commissioning - fills me with horror.

Your point about training is particularly worrying: our daughter is hoping to embark on 5 years at medical school in the autumn. I assume the bill's proponents hope that KPMG and McKinsey will set up medical schools as well as commissioning bodies.

@andrewzcooper

Andrew Cooper said...

PS - re the efficient markets hypothesis, I strongly recommend Edward Stourton's recent Radio 4 Analysis programme here http://www.bbc.co.uk/programmes/b019rlnv which includes interviews with people on the right who have increasing doubts about the nature of 21st century capitalism.

@andrewzcooper

LondonStatto said...

Yet more scaremongering.

Point 4, to take just one example, fails because the government is continuing to increase the NHS budget (though Labour want to cut it).

And the assertion that the NHS isn't broken is risible.

And, of course, whilst "once the NHS is gone it's gone", this Bill will not remove the NHS. Pure scaremongering. You should be ashamed of yourself.

LondonStatto said...

"I am not ascribing motives to GPs or saying that they will do things, but that these are things that people will suspect them of doing because"...

...because you made it up.

Andrew Cooper said...

As I noted in my first comment, I'd like to see some well argued - and preferably evidence-based - rebuttals of Christine's arguments. We're clearly not going to get those from Londonstatto, whose response is sadly typical of so many of those who support Lansley.

So does anyone else have suggestions about where we might look for the other point of view?

I'm perfectly prepared to accept there is another point of view. Unfortunately, as many including his colleagues have pointed out, Andrew Lansley is a very poor communicator so it's difficult to work out exactly what is going on.

The problem for Lansley is that this leaves the public in the position of asking themselves the question 'Who should I trust? A politician or nurses and doctors?'.

It's not a good question to have to ask but, as I say, in my view it's a result of the Department of Health's poor communication.

Gareth Stephenson said...

Andrew Cooper is right that we have a highly polarised, politicised, debate without much in the way of fact to underpin it. Many of the opponents of the Bill don't seem to have a clear idea of why they object, trumpeting phrases like back door privatisation, and many supporters are unable to give a coherent defence of what exactly it is trying to achieve.

The NHS is clearly not broken but neither is it in a good position to deliver high quality healthcare with leading edge treatment as the population ages, treatments increase in cost and complexity and those paying tax reduce as a proportion of the population. The huge machine which runs the NHS absolutely does need to be reinvented and slimmed, and the way it is funded needs to get past 1948.

For my part I have worked extensively in and with the NHS and in my book, The Unofficial Big Society Green Paper, I included a whole chapter on the subject. Many in the NHS will say there is enough money in the system now, it is the demographics, rising cost of treatment and rising health inequality that concern them. With issues like these they struggle to understand the changes, or at least the current relevance of them.

That said, I can see some merit in the proposals and suspect we will be stuck with the Bill in some form, so we need to make the most of it. I would welcome my GP being in control of the budget for all of my healthcare, and helping to lead community commissioning that ensures high quality local services, and so would she, provided that the provision of funding is fair, equal, transparent and sufficient to ensure no legal citizen of the UK is turned away. Also, I don't have a problem with competition provided it is between the right type of providers offering best of breed services. I cover this in more detail in my blog http://bigsocietygreenpaper.blogspot.com/2012_02_01_archive.html The blog explores two changes/actions may make the Bill much more palatable and much more likely to do us good.

I fully agree about the dangers in the Bill, and see that it is piling change on top of funding issues, but can also see that with a couple of tweaks it could be a positive force for all of us. As we're likely to get it anyway I think we must try to make it as safe and relevant as possible.

Gareth Stephenson said...

Andrew Cooper is right that we have a highly polarised, politicised, debate without much in the way of fact to underpin it. Many of the opponents of the Bill don't seem to have a clear idea of why they object, trumpeting phrases like back door privatisation, and many supporters are unable to give a coherent defence of what exactly it is trying to achieve.

For my part I have worked extensively in and with the NHS and in my book, The Unofficial Big Society Green Paper, I included a whole chapter on the subject. Many in the NHS will say there is enough money in the system now, it is the demographics, rising cost of treatment and rising health inequality that concern them. With issues like these they struggle to understand the changes, or at least the current relevance of them.

That said, I can see some merit in the proposals and suspect we will be stuck with the Bill in some form, so we need to make the most of it. I would welcome my GP being in control of the budget for all of my healthcare, and helping to leading community commissioning that ensures high quality local services, and so would she, provided that the provision of funding is fair, equal, transparent and sufficient to ensure no-one is turned away. Also, I don't have a problem with competition provided it is between the right type of providers offering best of breed services. I cover this in more detail in my blog http://bigsocietygreenpaper.blogspot.com/2012_02_01_archive.html

I fully agree about the dangers in the Bill, and see that it is piling change on top of funding issues, but can also see that with a couple of tweaks it could be a positive force for all of us. If we are going to get it anyway, we might as well work to make it as relevant and safe as possible.

Andrew Cooper said...

Many thanks Gareth, that's very helpful I'll take a look at your blog later.

Seems to me the devil is in the detail. On the privatisation point, clearly the NHS isn't being privatised in the same way that British Airways and BT were: moved entirely into the private sector, listed as PLCs and owned by shareholders rather than taxpayers.

This feels much more like the British Rail privatisation. As we know, parts of that went horribly awry with Railtrack having to be brought back into public ownership after a number of serious accidents.

Like many I have very little faith in the political process or politicians so I want to see some good evidence - or at least, a priori reasoning where evidence isn't available - that this huge raft of changes won't expose us to another Railtrack. I do think the onus is on those who are pushing through the changes to demonstrate that they've got it right, or at least as right as it's possible to get it in advance, and that where there are risks they've anticipated them and how they will be handled.

The experience of Private Finance Initiative funded projects also casts some doubts, in my mind about whether the private sector good/public sector bad mantra the efficient market advocates believe is really as efficient as it seems. Even George Osborne seems to have his doubts about PFI and announced a 'fundamental reassessment' last year.

Clearly the private sector has always and will always have a large part to play in health service delivery. It's when private sector firms - who, if they're stock market listed, have a legal obligation to maximise shareholder value - are running all/most aspects of delivery that we start to worry.

Listening to Lansley it's easy to get the impression that his main argument for massively increasing private sector involvement is 'Well, so were Labour'. This, of course, isn't an argument at all.

There's no doubt in my mind that how we fund and deliver health services has to change - everything has to change - but I have huge doubts whether the current proposals, which seem to have been rushed by a government which doesn't really have a mandate.

If we have, as you suggest, to accept that the bill will go through will there be anything that we can do to undo any damage that might be done?

I also have major concerns about the role of Mckinsey in all this, but that's another story.

Management summary: if most health service delivery and planning will be in the hands of the private sector, albeit funded by taxpayers, how can we be sure that they won't put the profit motive first and that the interests of patients and taxpayers will come second?

Andrew Cooper said...

Apologies for wittering on, but an analogy just occurred to me.

It would be perfectly possible for our armed forces to use contract personnel, rather than directly employed members of the armed forces. All strategic and operational planning could be handed over to KPMG and McKinsey and the actual fighting to Blackwater, or whatever they're called now.

Of course the private sector already provide a big role in defence - supplying hugely expensive weapons systems, and everything else, for example - but I think many people would be uncomfortable with the idea that all operations should be planned and executed by mercenaries. Ditto the NHS.

Gareth Stephenson said...

Andrew - spot on. State spend should never be managed by any entity other than an elected and accountable one. There is clearly no way it would be safe for commercial companies to hold the purse strings, and I don't think the Clinical Commissioning Groups will allow that to happen. The extent to which they are guided by the McKinsey and KPMG types is another matter however and something that must be watched.

The Bill in its present form seems to me to be about giving further power and profit to big business, despite the big society rhetoric of our leader. That was the reason behind my book, and the changes that I suggest in my blog are actually about calling the government's bluff on that.

If the Bill is genuinely to protect and enhance the NHS they will have no problem with my suggestions, which are in a nutshell to enshrine social enterprise as a delivery mechanism and ensure that we are all equal when treatments and benefits, even pensions, are being handed out.

A Big Society will simply not come about unless there is transparent fairness and equality across society, and that is the glaring omission from the current Bill, standing worryingly alongside the other risks that we can all see.

I don't follow the argument that private sector is more efficient or better than public sector, and I agree with your reservations about PFI and privatisation. They have both been expensive and messy. What is needed however is a more dynamic culture within the NHS and a proper strategy to deal with the challenges ahead. Unless they are built in to the Bill, I can see it ensuring that Cameron is not re-elected, whether it makes it into law or not, and that alone gives me some hope that further concessions will be made.

Andrew Cooper said...

Completely agree with you, Gareth, I might have to buy your book!

Must get on but just to pick up on the point about the widespread belief that the private sector is more efficient than the public sector, I think that it's just one of those things which has been repeated so often it has the status of fact. The public sector can be hugely inefficient but so can the private sector.

Seems to me that the public debate is currently in terms of 'Who should we believe?'. My response is: 'I don't want to have to believe anyone, I want facts and analysis so that I can make my own mind up'.

David Alexander Hough said...

I won't pretend to have anything beyond a layman's understanding of what is going on, beyond I have all the fears which Christine writes about.

So I'll stick to something I do understand, as we know the government have already performed the miracle of doctor training being reduced to 18 months, or at least that's the impression Cameron gave last week.

But seriously, if fewer doctors, nurses etc are going to be trained, how will this be affected by immigration caps, as the NHS won't have been employing or training these abroad?

Anonymous said...

Good point David, badly trained fewer staff, I had to complain about a local stroke ward on behalf of my friend, it's next to the dementia ward and every night patients come through onto the stroke ward so they barricaded the fire exit to stop it,you couldn't make it up

@woolhatwoman said...

I'm a patient, not a health professional, just a piece of cannon fodder. I get meds for 2 chronic health issues, not related to smoking, obesity, or dementia. I have signed the ePetition, re-Tweeted various links etc & emailed my MP (who neither replied nor supported the Early Day Motion asking for the Risk Register to be made available to the House of Lords in its deliberations on this Bill). Is there anything else I can do as part of the drop-the-bill movement?

David Hickson said...

The key point that underlies "the reforms" is in what they will enable in the very near future.

Gareth makes the point very clearly that for the NHS to survive at its present scale, and especially if extended as proposed, it will require additional funding from new sources.

There are many who believe that the principle of paying for healthcare through taxation and receiving treatment "free at the point of need" should end.

By invoking private sector involvement (where this principle makes no sense whatsoever) and allowing greater choice to the recipient of treatment (rather than those who presently pay for it), the door to co-payment is opened. The name may be stolen, but our NHS cannot tolerate co-payment.

The argument that taxpayers should not pay for "choices" exercised by others is already well established. Phase II of the reforms will therefore easily be accomplished once the impact of the increased cost of greater choice and the inevitable failure of continuing "efficiency" savings to address general price inflation start to bite.

The "clever" idea is that it will be public demand that leads to the abolition of the NHS in England, which is why this is only enabled, not put into effect, in the bill.

If a service is funded "nationally" then all the necessary controls must be in place at that level to ensure that the money is spent wisely and the benefit distributed properly. If the service is large, then these mechanisms are weighty.

The Bill is effectively taking away the justification for total central funding, thereby preparing us for the end of the NHS in England.

This is what we should be debating.

Anonymous said...

I support complete PRIVATISATION of the NHS. It is the only way the health service will improve and develop. I also believe that the last thing the NHS needs to be funding is sex change operations... humanity has survived hundreds of thousands of years without them.

Anonymous said...

in addition, the government have no money - only taxpayers money. they have no authority to spend our money on what they think is a good idea. it is akin to me going into your wallet and extracting money to spend on something that i feel is a good cause. let the market decide on everything.
i wish people would understand that socialism is just as evil as NAZISM(look at the Gulags in the former USSR).

Anonymous said...

Correct me if I am wrong. As per the new bill, the GPs will send a simple straight forward appendicitis to a private hospital known to them or where they have their stake (as in the GREAT MEDIEVAL TOWN OF YORK) while an appendix with perforation and peritonotis ends up in an acute NHS hospital. The former get dischaged in less than 48 hours a while the latter occupied Ward, ICU bed, has multiple CTs with possible re-explorations. The only common thing is that both get paid £2000 !

Anonymous said...

I support complete PRIVATISATION of the NHS. It is the only way the health service will improve and develop. I also believe that the last thing the NHS needs to be funding is sex change operations...****** humanity has survived hundreds of thousands of years without them*****

12:07 AM, February 14, 2012


Sure, as well as penicillin,plaster casts,cancer treatment, cataract treatment, asthma treatment, among hundreds of other treatments for health conditions. Because people simply died and those that managed to live, lived. So what is your point? Those who can afford it, live and those who can't, die.

OK well, I didn't realise we lived in the USA and that basic care comes at the cost of your house and everything else. I don't know what rose tinted glasses you are wearing mate, but ask my great grandmother and my grandmother and it wasn't pretty! People like you, scare me. You really really really do.

Jaccobs Smith said...

We discussed this in Everett walk in clinic and we do have different opinions about this topic. All that I’m saying is that if this bill will benefit the needy people in terms of their health care, then its fine to me.

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