Over the last couple of years we have organised and participated in many discussions about threats to the NHS, thanks to Mr Lansley.  These debates have provided an opportunity to reconsider many of the founding principles of the NHS, principles which have been taken for granted for many years.  This is an attempt to distil the wisdom of those debates, and we are grateful to all those who have participated.

The NHS is a large and complex organisation and it means different things to different people.  People who work for the NHS have a different perspective from most patients.  If we are seriously trying to defend the NHS we need to develop a clear vision about what we are defending, and what the threats to it are which we can communicate to the public.

Privatisation

“Health Ministers have said that they will never privatise the NHS“.  David Cameron repeatedly says that there is no privatisation – but he appears to be trying to twist the meaning of the word so that it means charging for services.  We prefer the World Health Organization definition of  privatisation in healthcare as “a process in which non-governmental actors become increasingly involved in the financing and/or provision of healthcare services”.

The SHA warned about the real intention of the Health and Social Care Bill in the Dark Side

Clive Peedel produced a very helpful analysis  of the privatising effect of the Health and Social Care Act.  As far as people who work in the NHS are concerned the key question when services are transferred to a different provider is probably whether the staff will still be in the NHS pension scheme with NHS terms and conditions.  The public, however, seem a bit confused.  If you ask people if they want to see their local NHS services privatised a large majority will say no.  But 56% of those asked by the Health Service Journal said they would not object to using a private supplier of medical treatment, so long as they did not have to pay.

The distinction between public and private provision has become more blurred over time.  Almost all the drugs and equipment used in the NHS are privately produced and always have been.  There are people who want to see the pharmaceutical industry nationalised, but they don’t seem likely to succeed in the near future.  As the technology becomes more complex NHS providers are increasingly entering into deals with suppliers to lease and maintain equipment, rather than buying it.  My local hospital in South Manchester has just entered a deal worth £50 million over seven years with Medtronic, who have won the contract to replace the hospital’s four catheterisation laboratories, on the basis that they are more expert than the hopspital’s staff as far as the kit is concerned.

Those who regard the biggest threat to the NHS as privatisation generally don’t have much to say about primary care.  GPs, dentists, opticians, and pharmacists are almost all private commercial enterprises – and always have been.  At least 90% of public contact with the NHS is with these private providers.  Even organisations like Keep Our NHS Public seem perfectly relaxed about this. In discussion it appears that the objection of most of their members  is not so much to private provision as to corporate provision. The issue is blurred anyway as many GPs have found ways to “profit” through taking interests in companies providing services. Their worry is not the profit individual doctors or dentists make but the prospect of exploitation by faceless corporations.  Or as our academic members put it: “due diligence across different jurisdictions in multinational corporations is poor”.

Of course faceless corporations include drug companies, medical equipment providers, IT suppliers and others all of which make profits from dealing with the NHS.

It was the policy of the Socialist Medical Association for many years that “doctors working in primary care services should be whole-time salaried employees”.  In recent years we haven’t talked much about this, because it seems to be coming about, but not in the way that we envisaged it.  About half of all GPs are now employees – mostly employed by the declining number of other GPs who are partners.  Changes in the structure of primary care may be very significant for the future of the NHS, but have attracted little attention outside the GP profession.

The proportion of NHS hospital activity supplied by the private sector increased, but not by very much, under Labour. Most of the increase was  in routine surgery. This was claimed to be necessary to reduce waiting times which was a policy very popular with patients but not clinicians.  In mental health a much higher proportion of work has been contracted to the private sector for a long time.  In surgery the private sector are accused of cherry-picking – ie only doing easy work.  In mental health the opposite is the case. The private sector mostly does long term, expensive and difficult work – people with learning difficulties and challenging behaviour, eating disorders and the like.  If we are going to use the private sector at all it might be sensible to use it for work of which the quality can easily be monitored.  As Winterbourne View showed, it’s not difficult to take a lot of money in this sort of work and provide a dreadful service. In mental health there aren’t many objective measurements of quality or success.

For Any Qualified Provider contracts, which have long been the norm for eyes, teeth, and drugs, we can see that quality can be defined and measured, there are lots of alternative potential suppliers and that the service is largely independent of other services.  In such cases many argue that having multiple providers including private ones does little harm and can drive improvements.

We should however be worried about developments such as at Hinchingbrooke and at Cambs and Peterborough where it looks more like private providers running whole organisations in mainstream NHS.

We cannot easily demonstrate that the quality supplied by private health care is worse than what is supplied by the NHS, though of course it is easy to suppose that it would be.  There were many scandals in the NHS long stay hospitals for people with learning difficulties  before they were closed.  In general the private health sector in the UK is not easy to compare with NHS provision.  The private sector has been concentrated in what might be termed boutique operations –  small sectors which for various reasons the NHS does not provide.

All this shows how hard it is to define what comprises our NHS in a way which excludes private providers.

Accountability

One of the distinguishing features of public services, as opposed to private, is that they should be accountable to the public.  Nye Bevan famously said that  “the sound of a bedpan falling in Tredegar Hospital would resound in the Palace of Westminster”, but succeeding Secretaries of State – Labour as well as Conservative – have generally felt that this was an unsatisfactory model of accountability.

Prof Alysson Pollock says that the National Health Service was abolished on 1st April. In her terms she is right.  The Health and Social Care Act removed the duty of the health secretary to provide comprehensive healthcare. This was a central issues in the debate over Lansley’s reforms, and the Labour Party have pledged to reinstate the duty.  But the political reality is that accountability for the NHS still remains with the government even if Jeremy Hunt can claim that its nothing to do with him. And those who think the NHS has already been abolished are a very small minority.

Throughout its history the NHS has used its most opaque approach to determine how resources are allocated and priorities are set down to localities – albeit within a system which is both universal and comprehensive.  Key decisions have always been made behind closed doors by unaccountable, unelected and unrepresentative bureaucrats and have been heavily influenced by vested interests and special pleading.  Years of PCGs, PCTs and CCGs have actually changed little around resource allocation.

Labour’s plan, which has been adopted enthusiastically by the Government, was to make all NHS Trusts into Foundation Trusts, which are, in principle, accountable to their members.  However this model has no political credibility.  Of those who have come to discuss their local NHS at our events less than 10% were members of any Foundation Trust, and even those who were members – or in some cases elected governors – did not regard the democratic arrangements as anything more than decorative.

The Act established new local involvement structures.  Local Healthwatch, the latest replacement for Community Health Councils, so far looks very weak.  It’s remit has been expanded but its funding and profile have contracted.  Individual Clinical Commissioning Groups have to make their own local involvement structures, and there seems to be widespread agreement that these are an improvement on what was done by PCTs.  PCTs became increasingly insensitive to local communities as they became more subject to central direction.  CCGs may, of course, go the same way.

Many express the view that commissioning and provision should not be separated, but there is confusion about the difference between planning, strategic commissioning, procurement and purchasing.  In any system there has to be some planning and decisions are made about allocating resources and priorities.  It appears obvious that these decisions should not be made by those who provide the services eg GPs can hardly decide for themselves how much they should be paid and what they are required to deliver; hospitals can’t just decide what services they provide, staff up and pass on the bill.  The long history of the NHS has been tarnished by the way vested interests and historical settlements have taken priority over more sensible ways to provide funding. One of the more dreadful aspects of the Health & Social Care Act is that it effectively removes any idea of planning – it leaves it to the market.

Private Finance Initiative

PFI is fundamentally a much wider issue than the NHS, although the use of PFI in health is the most incompetent.   Of course it’s more expensive to finance developments commercially than directly from Government funds – but direct Government funding has never been widely available.  Paying the charges for PFI schemes is of course a burden on individual NHS Trusts, but perversely, as has been demonstrated in South London having a PFI scheme means your hospital will not be closed.

Annual payment schedule for all NHS PFI schemes

Annual payment schedule for all NHS PFI schemes signed before 15th June 2010 over contracts’ lifetimes

It is often forgotten that the use of the financial model for PFI was only one part of the problem.  Most PFI hospitals were justified based on projections about activity that were signed off by the NHS but very soon turned out to be badly wrong.  The gold plating and over engineering of PFI buildings was signed off by all and sundry.  Many of the benefits around service changes that clinicians and others signed up for – to justify the new build – were never delivered.  The use of private as opposed to public finance just made it worse. Even without PFI most of the projects led by the Department of Health would still have been poor value for money.

Competition and choice

Under the new regime established under the Health and Social Care Act competitive tendering has become much more widespread, especially in the provision of community services.  As might be expected this is leading to a significant expansion of non-NHS provision.   However this expansion is primarily in areas where patients have little choice. In community services, as in mental health, patients generally don’t have any choice about where they are treated.  They are effectively the commodity out of which the provider hopes to make profits.  This sort of competition has nothing to do with patient choice.

Conspiracy

The report that Oliver Letwin  told a private meeting that the “NHS will not exist” within five years of a Conservative election victory has been made much of.  Other Conservatives have said the same sort of thing in the past.  But analysing every policy development in terms of a conspiracy is not very helpful.  After all, our opponents could point to Labour Party members who wanted to nationalise the 200 largest companies, but those ambitions have not been realised.

There are Conservatives who object to the whole idea of the NHS and would like to replace it with an American type insurance based system, but they are kept locked up in a basement somewhere.  Every serious politician understands that moves in that direction would be political suicide.

We know that there are many from various parties and persuasions who do believe that more competition and more entry for other providers is good for the NHS. But we should accept the fact that the current regime is using every opportunity to open up the provision of services to private providers.

Principles of the NHS

The SHA has for many years argued for “Universal healthcare meeting patients’ needs, free at the point of use, funded by taxation.”  We still think that is the fundamental principle that needs to be defended.

Bevan had more to say about the ideas behind the establishment of the NHS.  The one I like best is “The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged.”  This, like many of the ideas around the NHS is more an aspiration than a principle, but that does not mean it’s unimportant.  He also said “Warm gushes of self-indulgent emotion are an unreliable source of driving power in the field of health organization.”  But he said very little about the merits of public versus private provision.  Public provision does not appear to have been a principle for him.  If we now think its an important principle then as far as most of the public is concerned, we need to explain exactly what the principle is and why its important.

Free at the point of need

Charging for GP consultations is popular with GPs, not as a way of raising money, but as a way of controlling demand.  But it might not work.  If people pay for something they feel a greater sense of entitlement. The people who would be deterred by a charge of £20 or so would be people who would turn up in hospital when their problems are more serious and more expensive to treat. Richer people, who on the whole are less in need, would pay their £20 and demand to be seen more often.

Some hospitals have tried to offer NHS type services for money when commissioners would not pay for them – for example IVF treatment for infertility.  Their reasoning is that they are prepared to give patients an identical service to that given to NHS patients, and for the same price.  Typically private patients get more frills – private rooms and so on – and they are charged more than NHS prices.  Although we sympathise with the intentions we think this is dangerous territory.  The principle that NHS treatment is free unless charges are agreed by Parliament is important.  If you have to pay, however little, it’s not NHS treatment.

Comprehensive

In 1948 patients could be  told the NHS “will provide you with all medical, dental and nursing care.” However what could be provided was very limited by today’s standards.  There weren’t many treatments that worked.  The NHS had a lot of beds but not much else. There wasn’t any talk about rationing.  But as more treatments have been developed the NHS, like every other health system, has introduced measures intended to ensure that only cost-effective treatment is paid for.  We regard the establishment of the  National Institute for Clinical Excellence as one of the most important achievements of the Labour Government.

General government expenditure on UK Health Services: 1950/51 to 2010/11

General government expenditure on UK Health Services: 1950/51 to 2010/11 in 2011 prices

It seems inevitable that more decisions about what treatment can be paid for under the NHS will have to be made. Politicians are uncomfortable with the idea, but all medical treatment is rationed, everywhere.  We should spend our money on the most cost-effective treatments until we’ve used up all the money.

That leads us back to the previous point.  There are already plenty of procedures that the NHS will not provide because they are not regarded as good value for money (the Croydon List), and there will be more as austerity bites deeper.  Some of them are things that some patients would be prepared to pay for.  When we considered the question of “topping-up” NHS services in 2008 we said   “We stand by the line that the NHS – and its staff – should not be offering or delivering additional or better treatment for money.”  That was in the context of privately funded chemotherapy.  Do the same considerations apply, for example, to the removal of tattoos?  If  NHS providers don’t do this sort of work then private providers will.

Defending the National Health Service

Andy Burnham’s position is that the NHS should be the preferred provider of health services.  He hasn’t clearly explained how exactly decisions would be made to contract some other provider. It was Andy who initiated the process which led to Circle getting a  management franchise to run Hinchinbrooke Hospital. There the private sector was used as a last resort – and it still remains to be demonstrated that the private sector can deliver something the NHS could not do.

A commercial health system has no incentive to keep people healthy.  One of  the principles which inspired the setting up of the NHS was that it should be preventative.  The Government’s move towards a more consumer approach to health care undermines that idea.  Medical treatment is not like consumer services.  It isn’t a good thing in itself.  No sane person wants more medical treatment than they can avoid.

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10 Comments

  1. “If we are seriously trying to defend the NHS we need to develop a clear vision about what we are defending”.

    I agree. It is a shame therefore that whilst there are some good aspects to this piece, the overall feeling one is left with after reading it is one of confusion.

    For example, the reading of public opinion is selective (it is not just ‘local’ privatisation that most polls show strong opposition to), as is the reading of the position of GPs in relation to charging.

    The arguments regarding on private suppliers of medical equipment, the salaried position of GPs, and co-payments are both familiar to readers of this site, and problematic. The way they are argued, leaves too many hostages to fortune for all those who would use the ‘never perfect’ state of the NHS to massively lever in the market – something the government is obviously keen to do.

    Overall the article appears in some places to suggest that the battle is already lost and it is time to admit defeat, whilst at the same time suggesting that most people think it’s ok, and it would be politically mad to damage the NHS, so all must be ok.

    More interesting challenges – like why people don’t realise the NHS is being privatised, how politicans are getting away with it, what we can actually do about PFI, the use of private providers in particular areas, and most of all, whether the ”internal market’ does more harm than good – are not analysed. Instead, these key controversies are glossed over, the need for an evidence base evaded, with phrases like “it seems obvious that…”, “if we are going to…”. “Many argue that…”, “It has long been the norm that…” “It seems inevitable that…”

    To genuinely develop a clear vision, we need to unpick such phrases.

    To use them uncritically, strips out the history of changes to the NHS, particularly those which were implemented under the last labour government, whether they were wise – or not – and what saner alternatives might be.

  2. Having said all of that the piece does raise interesting questions about rising demand, expectation and technological possibilities, that need addressing. It is just a shame that the context in which these important points are raised, is so muddled.

  3. I think these guys have given up.MR is assimilating homogenously.The outrage that the tory government has perpetrated on the NHS and it’s beneficiaries-us,the sleeked and devious means they have used,the fact that 225 mps and lords have financial interests in private healthcare[this is obscene and has hardly sullied the headlines],the fact that the tories have got significant funds from private healthcare business,the fact that Mckinsey and Company who virtually wrote the rancid document represent some major health corporations,the change from the secretary of state for health no longer having a duty to provide healthcare,only a duty to promote it-how weasally and repugnant is that cop out and betrayal[and this went back for amendment and came back exactly the same,rewritten,the fact that most medical professionals objected to it,the fact that the chosen few were the consultees,the fact that £3billion was extracted to pay for it’s implementation at a time of great austerity,that pathways were not prepared when peoples’ lives and suffering were at stake,the assumptioon that people are such jerks that ‘free at point of need’is all they care about-not as mercenary as the tories-WE STILL HAVE PRINCIPLES,GOD DAMN YOU!WE STILL HAVE A CARE FOR OTHERS,GOD DAMN YOU!WE’RE NOT ALL MOTIVATED BY POWER AND MONEY AND STATUS,GOD DAMN YOU!
    In among all this,apart from an incompetent[of eye-watering incompetence]the model of marketising the Health sector,and provision by the private sector has not been established,but it’ll work for the tories and their corporate paymasters.
    I would say to Mr Rathfelder,Are you not completely pissed.
    ‘ If You Tolerate This Your Children Will Be Next.’
    It’s intolerable.Unacceptable.Morally repugnant.Corrupt.Anti-democratic.

  4. Martin Rathfelder says:

    We would welcome ideas about how we can present coherent alternatives. This article is based on about 40 discussions we’ve conducted around the country – and yes the picture is muddled. But it is very difficult to present public provision, in itself, as a principle. If we think, as most of us do, that more commercial healthcare provision is undesireable, we will have to argue pragmatically.

  5. Thank you Martin, for this honest and balanced view. I agree with nearly every word. I support the government’s changes, particularly the filling of the democratic deficit in health, and creation of Health and Wellbeing Boards (HWB) to sign off the NHS strategic plans to avoid the catastophes of the past.. For example, there is a project costing £420 m to revamp the Royal Sussex County Hospital which I hope the CCG will refuse, as it is gold plated and over engineered. The priority is to treat people in the community in primary care, and keep them out of secondary care, for the reasons you state.
    I have written several reports for my HWB in Brighton and Hove, which are published on http://www.reginaldkapp.org, section 9.56- 61. I am asking them to persuade the CCG to make the mental health service patient centred by opening it up to the existing community providers of therapeutic courses, (like Wiltshire) rather than the provider centred, assessment obsessed service we have in Sussex. I have an e petition on http://www.brighton-hove.gov.uk calling for more mindfulness courses, and am speaking to it on Wed 11.9.13

  6. shropssheila says:

    The community are the people who know best what is needed. There needs to be a forum where their views can be aired and discussed.

  7. Cicely Thomas says:

    This is a very interesting compilation of many differing views! I would agree that distinctions between what is public and what is private provision has become very blurred – we all have to pay for dental treatment unless v poor or a child. It would not be possible to nationalise the pharmaceutical industry, but measures could be taken to control price fixing and exorbitant charges for drugs to the NHS. One key aspect is that any and all private companies will put the profit motive and dividends to the shareholders before putting money into improving sometimes costly and difficult problems. doctors are increasingly being ‘exploited’ by drug companies. doctors have enough to do without having to deal with rapacious private providers out for their business!
    the biggest scandal is the privatisation of services to the vulnerable – care and ‘out of hours provision’. Elsewhere the private running of expensive facilities is defended, but the care must be inspected and regulated and be of high quality – but that goes for NHS hospitals as well. Power needs restoring to the Health Secretary and with teeth!
    The ‘market’ cannot work for services such as Health and Education – there is nothing to sell, and the consuming nature of these enterprises should and must be funded through taxation. Everyone uses the Health service and education at some point in their lives.
    It is the idea of allowing competition and choice unbridled access to the Health service which will destroy the concept of the NHS. Bevan’s principle should still hold – free at the point of need and making sure that rich and poor are treated alike.
    As with schools, if people are allowed to ‘opt out’ of the system by paying (in larger numbers than at present) then the public service will be diminished and the poorest will suffer.
    Agreed that population is rising, we demand more care and live longer. Treatment may have to be rationed, but this should be universal and not by post-code lottery. We need a new ethical stance on provision of health care – our ethics philosophers should meet and design some new rules for the 21st century – to cover all the new aspects of treatment and procedure going forward for the next 20/30/50 years.

  8. Sue ANderson says:

    I think this article is a fair reflection of the discussion around the issues, it is interesting that so much of the NHS actually depends on small business men and women (eg doctors, opticans, pharmacists etc) and no-one turns a hair. But I remain unconvinced that having large corporations bidding for services currently provided by the NHS will improve patient care or improve value for money. Interesting point about mental health provision and the difficulty of monitoring vfm.

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