THE HEALTH & SOCIAL CARE BILL 2011
We would be grateful if you would consider signing the e-petition below, asking that the Coalition government scraps the NHS Reform Bill. The e-petition will take no more than 60 seconds, but 60 seconds could prove invaluable to avoiding the destruction of the National Health Service. View the e-petitionThe Health & Social Bill has had a chequered passage since it was announced as proposed legislation for England on 19th January 2011. The Secretary of State for Health (England) proposes wide-ranging changes to the delivery of health care and how it is commissioned. The Bill will ensure a complete overhaul of the NHS structures at the same time, on a scale never previously seen.
As the Bill enters its second reading at the House of Lords we appeal to the Lords and Baronesses to reject the Bill as it will have far reaching consequences for the health services and the population that it serves. The reforms will increase the stake of private companies in the NHS, so that instead of GP led primary care and consultant delivered hospital services we will witness ‘Any Willing Providers’ picking up the most lucrative operations, with the NHS left to provide complex, costly care. A market-based competitive spirit will ensure that only the fittest survive, and Monitors changing role will do nothing for long waiting times, rationing of treatments and new charges being introduced. Vitally, the Health Secretary will no longer be able to intervene as he would have abdicated from responsibility to oversee the provision of universal health care.
The destruction of the NHS will be engraved on the coalition’s political gravestone and it will have a significant adverse effect on future generations, unless the House of Lords steps in. All other efforts appear to be failing. Furthermore, delaying the passage of the Bill will be damaging to the country’s economy therefore we would respectfully suggest that the House of Lords rejects the Bill in its entirety, and signals that the NHS needs an incremental reform which can be implemented without this damaging Bill.
THE PHILOSOPHY OF THE NHS
The National Health Service was founded in the post war years by a coalition government that had become acutely aware that soldiers were offered a better standard of care than civilians were. It was evident to politicians that every UK citizen deserved the best standard of care, regardless of where they came from, and who they were. This underpinned Bevan’s desire to make the NHS publicly funded, with no other source of funding or income, with the result that the NHS became a publicly owned, state-run service. He was forthright in his view that all hospitals should be nationalized, and as he symbolically took the keys of the NHS at Trafford General Hospital the die was cast for much of the next 60 years.THE CASE FOR REFORM
We would be the first to concede that the NHS is far from perfect. Most of us want NHS reform so that the taxpayers' money can be well spent for meeting modern day challenges such as obesity, depression, the ageing population, alcohol-related problems and spiraling demands of chronic illnesses. But the health secretary Andrew Lansley's recipe of GP commissioning, abolition of primary care trusts and strategic health authorities, with no coherent structures to replace them, the introduction of private providers into the NHS, and emphasis on cost rather than quality of service, lays personal dogma before rational political justification for reform.
The NHS has undergone major reforms periodically over time, some necessary and some as a desire of successive politicians wanting to outdo each other. But there is a need to keep up with the times, and since the NHS has never been fully funded for the duration of its existence (Margaret Thatcher famously stated that ‘The NHS is a bottomless pit’), it has been a challenge for all governments to improve financial efficiency whilst ensuring the quality of care given to patients has not been affected. The latter has been largely through the efforts of a loyal and highly committed workforce, the ‘NHS family’.
Radical reforms introducing market forces were first introduced by the Thatcher government in 1991. Fundholding made GPs more aware of how resources were spent, but introduced a two-tier health system while failing to sufficiently change the behaviour of clinicians. Indeed, the purchaser/provider split led to major conflict being introduced for the first time in the NHS workplace, leading to divisions of primary and secondary healthcare provision which, to a large extent, still exist today. But it was the introduction of management that has been the most fundamental and endearing change of the Thatcher years.
The Blair years saw a drive to improving quality of care by competition, with long strides into ensuring that private providers were given equal parity, or even preferential rates, wherever possible. New Labour’s then Health Secretary, Alan Milburn, strongly promoted these principles, which have now formed the basis of many of the reform initiatives.
However, the current reform proposals are bolder, wider, and above all, costlier, drawing various national bodies such as the BMA and the RCN to openly criticise them. The Prime Minister’s parliamentary speech suggesting that the reforms are well supported by the Royal Colleges and health workers would not stand to scrutiny. The BMA has openly asked the Bill to be withdrawn, the RCN has passed a vote of no confidence in Andrew Lansley, a large number of scholars have written openly in the Telegraph for the Bill to be withdrawn, and notable Liberals such as Baroness Shirley Williams and Dr Evan Harris have come out in opposition. In fact the deputy PM, Nick Clegg, has himself stated that ‘No Bill is better than a bad Bill’.
It is worth reminding ourselves that there is no mandate from the public or either party in the coalition to this reform.
THE ECONOMIC ARGUMENT FOR REFORM
The Bill contains many contentious issues that have yet to be resolved despite the wide scale opposition and a ‘Listening Exercise’ which made significant recommendations but which have not been fully incorporated into the amended Bill that appears before the Lords.
Key to Lansley’s reforms (dubbed Lansley’s Monster by the BMJ) is economic efficiency and a target of £20 Billion to be achieved by 2015. This is an impossible target to achieve, for many reasons. Even during the sternest times, the NHS has been expected to run a cost efficiency reduction of 4% despite the evidence that only 2% was achieved at the most. Against a competing demand of more expensive treatments and high patient expectations it is just not possible to improve financial efficiency to the extent the coalition government proposes without it seriously affecting patient care. Peers may also want to ask the coalition government the question: “Is this Bill necessary, given the current state of the UK economy?”
A RADICAL ALTERATION TO THE STRUCTURES
Overlapping with the desire to cut the budget is also the fact that Lansley has pledged to abolish the PCTs and the SHAs. A parallel structure of consortia and commissioning bodies is being put in place, which in itself increases the costs, but what is less transparent is that senior managers are being made redundant, adding to the cost. It has to be a concern that some of these personnel will then be re-employed in the NHS, leaving many to wonder whether the trauma of reform is making the economics of running the NHS worse rather than better even before any agreed reforms are embedded. The projected cost of the reorganisation is £3 billion, which is money that is drawn away from frontline provision of care. These changes at the top layers of the NHS are already being introduced in a rather haphazard manner, and rather than make the whole business of commissioning and providing simple, the final outcome will be more bureaucracy in the NHS, and less devolvement of power to local bodies.COMMISSIONING
A further concern we have is that commissioning as proposed has never been tried and tested elsewhere. The coalition intends to make GPs responsible for all commissioning other than that of specialist services. The flaw in this argument is that GPs are not experienced in commissioning, many do not want to do it, and also it will take those very experienced GPs who do take the role, away from providing patient care. These GPs are likely to be at a level of seniority where they are a major asset to patient care. Drawing them away from patient care is likely to have consequences for primary care. For those who intend to commission and have the resources to do so, it seems less than clear how any conflict of interest will be overcome. Those who commission will be permitted to provide a service too, effectively increasing the scope of self-commissioning and self-profit.PRIVATE HEALTHCARE
The most contentious part of the Bill is the Secretary of State’s intentions to introduce private health care well beyond the vision of any previous government. There is already scope for Foundation Trusts to increase their income from private providers, but so far they have been cautious not to do this as they still operate under the framework of the NHS Constitution. Removing the barriers will mean that waiting lists will target patients with higher resources than the NHS tariff, private patients will be prioritised over NHS patients, and the real threat is that the elderly and the vulnerable, those with chronic mental health problems, those with chronic medical problems such as diabetics, renal patients, etc will be a low priority. There is every possibility that the reformed NHS under these proposals will become exclusive rather than inclusive. Removal of a cap over private income will see Foundation Trusts competing over costs rather than quality, so that those that are run by poor management will risk the stability of the hospital to a much greater extent than prevails now.CONCLUSIONS
The authors have a combined experience of nearly 60 years in the frontline of the NHS, and this perspective from general practice and hospital services (much of it at senior levels) is necessary to provide a critique of the Health and Social Care Bill. We believe this is the wrong reform at the wrong time. We are opposed to the Bill for the reasons stated above. There are many in the health services who share our views, and for all of these loyal NHS workers there is one single motive – that is, to keep the NHS as a publicly funded service, for the good of the people, and not one that is only there for those with the means to access care or for those who can benefit financially from the ill of others. We believe that these reforms will pave the way for substantial privatisation of the NHS, and it will set us apart from other health services in the UK - in Wales, Scotland and Ireland. Peers might wonder too why these our closest neighbours are not rushing to introduce similar reforms in their nations.
Please reject this Bill in its entirety. Once enacted, it will be impossible to reverse the damaging changes it threatens to impose, thus sealing the fate of the NHS.
Dr Kailash Chand OBE, Dr J S Bamrah, FRCPsych,
Chairman, Tameside & Glossop NHS, Consultant Psychiatrist
‘Garcliffe’ North Manchester General Hospital,
34 Astley Road, Delauneys Road, Stalybridge, Crumpsall,
Hyde SK15 1NJ Manchester M8 5RB