Jos Bell discusses the real life implications of the coalition’s NHS proposals
It seems the overriding hands off ethos lurking within the Lansley Bill lies in the key phrase in Clause 4 ‘the Secretary of State’s duty as to promoting autonomy’. The protesting voices of the medical and associated professions are clamorous. Last week The Times played host to a signatory letter of 301 eminent medical specialists; BMA chair Dr Hamish Meldrum and Laurence Buckman, chairman of the General Practitioners Committee, penned a strongly worded open letter pressing home the reality of the risk; letters to the BMJ, The Pulse and just about every medical journal and professional body sound the alert.
Allyson Pollock, Professor and Director for the Centre for International Public Health Policy at the University of Edinburgh ably demonstrates the conflict between cost-savings, quality and safety. Outsourcing health services to private companies only adds to the layers of unaccountability - or as Lansley would have it, “autonomy”.
Of course, Lansley’s press releases make no mention of the involvement of the private corporations such as Mars and Unilever who have played a key role in his planning meetings since September last year (possibly with a view to feeding sweet tooth and alcohol addictions on prescription?) No mention either, is made of hundreds of thousands of pounds in donations to the Conservative party from private health companies.
The Lansley ‘offer’ is one where providers (minimum being a partnership of two - aka company directors) will be able to offer services to commissioners at less than the published mandatory tariff price. Essentially the NHS is to become a car boot sale where the patient may find themselves increasingly likely to be offered a dud replica.
Notwithstanding such a purchasing squeeze, in the instance that the health needs of the local populus fall into the over-pricey range a ‘Contingency budget’ clause has also been included in the Bill. Consortia are thus encouraged to plan for savings from their annual allocation in order to stay within budget when times get tough.
This free marketeering is a completely inappropriate economic model for health care because the element of risk per patient bears no relation to the ability of the patient to pay for their care. A mutual taxpayer investment in national healthcare services produces a mutual benefit – from having a healthier work force, from keeping epidemics in check, from a greater mean level of health in the population etc; to Lansley and the rest of the front bench, however, low taxes and maximum profit appear to be all.
The development and implementation of integrated care pathways to provide seamless care for patients is an ideal which is not remotely compatible with enforced competition between providers, as proposed in the Bill. Conversely this will only make it more difficult for GPs and hospital doctors to collaborate or for different providers to work together efficiently and for the benefit of patients.
Of course none of this was even touched upon in either ruling party manifesto - but hovering spectre-like in the wings, the White Paper was hastily cobbled together by Lansley in just six weeks following the election. The initial consultation period fudged into the dog days of summer ’10 when the leadership contest was in full throttle and Andy Burnham and Mary Creagh were lone voices in the recess wilderness calling ‘foul’.
How any of this falls into the aims of the Ljubljana Charter on EU healthcare reform is a complete mystery. Rather it exploits the laudable aims of choice, prevention and primary care excellence into a twisted sister of corporate profit. This Bill is all about patient detriment and not a jot about quality care or early intervention.
Along with the majority of the medical profession, the vast majority of GPs themselves do not approve of the commissioning responsibility which is being foist upon them.
Ninety per cent of all doctor consultations are with a GP, however the assessment of GP performance is problematic - which is likely to lead to further problems in monitoring delivery, although past reference to the failure of ‘GP Fund-holding’, which was an integral part of the NHS ‘internal market’ introduced by the Thatcher government in the 1990s demonstrates the risk.
GPs will be obliged to ration services but their decisions will not necessarily be transparent or publicly accountable. Far removed from the original model of the NHS, the Commissioning Boards will be a business partnership - essentially an enterprise established for the benefit of the partners and shareholders. The question must be asked: Who is going to act as advocate for the patient and ensure all of these conflicts of interest are addressed?
This is the point where the NHS ceases to be a public service. The transfer of £80 billion pounds of public money to GP consortia is a giant shift in power away from the underpinning principles of the NHS. In the future, GP practices will employ the rump of the NHS or choose instead to employ private contractors to do the work, and their decisions will be subject to the laws of trade and competition, rather than based strictly on clinical concerns.
Practices will get bigger and, like lawyers and accountants, migrate to more hierarchical organisational models which distance themselves exponentially from the patient. To secure their viability, consortia are encouraged to aim for a patient catchment of 500,000-750,000 but will also include sub-groups to enable local communities to have meaningful clinical engagement. A profound challenge for both rural and high need urban areas alike where running costs are likely to exceed the Department of Health allocation.
Unison described the reforms as a Lansley “vanity project” for the health secretary which was:
“…unnecessary, badly-timed, ill-thought through and damaging.”
Head of health Karen Jennings argued:
“Lansley’s so-called consultation was a sham and a foregone conclusion. By forging ahead with his plans in the teeth of fierce opposition from leading health experts, patient groups, staff, unions and GPs themselves, he is showing an utter disregard for the long term future of the NHS.”
Even before the consultation period was ended, PCTs have been haemorrhaging staff with or without a redundancy notice and their premature collapse, without anything coherent to replace them, has meant that some GPs are feeling pressured into surging ahead with consortium development despite their misgivings.
Far from the much vaunted cost saving, the ‘Change Agent’ bill is a massive £3 billion where the cost savings will then be forced out of the patient care allocation (already sliced under the guise of viring the social care budget under the overall spend). It is estimated that there will be 20,900 redundancies amounting to a £1bn redundancy bill. Of course the best of these will then be re-employed by Consortia as the staff, consultants and researchers. A bargain!
In the midst of this massacre, there is a further sadness. Both Wales and Scotland with their devolved powers have developed integrated models of delivery which are starting to meet patient needs in a cost effective and co-productive way where the internal market has been declared void. Lansley is now forcing English health into a totally different direction under the patently false claim that his Bill will drive up standards and reign in prices.
The price for the nation’s health and well being is high indeed. The only thing that stands between this Bill and national disaster are those of good conscience in the Commons and the Lords for whom this travesty of consultation and implementation is just one unhealthy step too far. This is indeed the time to be counted.