Ten questions for the Coalition government
You propose major changes to the NHS. As UK citizens, we would like to know the thinking behind these changes. Please could you answer these ten questions on the proposed reforms?
What is your democratic mandate for change?
Both parties in the Coalition government had manifestos which emphasised continuity for the NHS. Mr Cameron in particular emphasised that a Conservative government would not ‘mess with your NHS’. Within weeks of being in government, radical proposals for reform were declared. These had never been shared with the electorate prior to the national vote. What makes you think you have a mandate for change?
Who is pushing for these reforms?
More generally, who is pushing for change now? Who champions these reforms? You, obviously. But what of other stakeholders – your colleagues, medical unions, patients groups, voters – what is the evidence that any of the most important stakeholders now buy into this vision of change? Even most GPs, who in theory stand to benefit from greater power and funding in the new system do not appear to be leaping forward to be your new vanguard. Polls also indicate that the public were very satisfied with the NHS at the time you came into office.
What evidence is there that the NHS needed (re)reforming?
What is the evidence showing that we needed this change? While a few examples of cancer survival rates were trotted out in interviews, have you looked at the overall performance of the NHS in relation to other health systems and made a fair comparison of how we are doing and whether we need radical change? In comparison with most health systems, the NHS has been one of the most efficient, in terms of value for money, and also one of the fairest in terms of access for all. Why mess with it?
What is the evidence that these are the right reforms (if reform is needed)?
What is the evidence that these reforms will bring benefits (greater than their costs)? Where are the examples that we are following? Why not systematically pilot before going to national scale? What are the possible adverse effects? How will they be managed? What is Plan B, if it all goes horribly wrong?
Are the reforms consistent with the drive for cutting public spending?
Reforms are expensive - the costs of shutting down old structures and setting up new ones is going to be high. The costs are not just financial but also human and social, as with all organisational change. Why an expensive restructuring during a period of stringent public sector funding cuts (which affect the NHS in real terms, even if not nominally)?
How will the reforms drive efficiency and health gains?
Under the reforms, 152 health authorities (called PCTs) will be replaced with a greater number of GP consortia – with NHS hospital spending decisions by this new kind of health authority (not by your local “GP” as in the short hand used the media). In Leeds, for example, there will be four, the same size and number as before the last reform. The NHS has suffered endless restructuring. Why should these structures be better at their job and cheaper to run that the ones they replace? What capacity will they have to purchase such a wide range of services, unless they simply re-hire staff from the PCTs or buy in services from the private sector? In which case, how will they be any ‘closer to patients’ than the structures they replace? Were other less disruptive options for making efficiency savings considered? The PCTs were already being slimmed down, and GP commissioning was in process, before Lansley’s proposals were tabled.
How will we ensure that the NHS remains a system, not a market?
What is the evidence that markets work for health care? As the US amply illustrates, markets in health care lead mainly to price escalation and fragmentation. What is the evidence that the UK public wants choice, rather than good services? Similarly, on the health provider front, do health staff want to be in competition with one another, or to develop collaborative relations so as to offer a well-integrated service? How will voters respond when their district hospital closes after many core services have been contracted out elsewhere?. Why shouldn’t the NHS be the “preferred” provider?
How will care be rationed?
All health care systems are rationed. The NHS is almost unique in not rationing according to ability to pay. Instead, it had NICE, a world-leading body which used rational cost-effectiveness principles to prioritise the use of public funds. How will the cost pressures of new technologies and patient and commercial lobbying be managed in the new system? What is the gain from taking away NICE’s authority? If each GP commissioning group has to decide, won’t that put them under enormous, unnecessary pressures and lead to inequalities across the country? GPs fear the loss of their impartiality and loss of patient trust.
Who will own the assets?
The reforms hand over the bulk of public funds to GP consortia, led by the most business oriented GPs. If they reinvest in their business, they own the assets. Is this a good idea? How will the British public feel about their taxes being privatised in this way?
Are you open to consultation?
If, as seems to be the case, the evidence and professional and public opinion do not support your plans, are you willing to change them? It is not too late. Unless there is clear evidence to support these costly and disruptive changes, they should not be made. Why not evolution rather than revolution for our much loved NHS?
Sophie Witter (Health Economist) and John Walley (Public Health Physician Leeds and GP)