Both the SHA and the Labour Party have developed policies that are designed to remove the market structures from the NHS and to return to an integrated managed system with a Secretary of State politically and legally accountable for its performance. Both have argued that a top down reorganisation is unnecessary and to be avoided; legislation is required to repeal the market related part of the 2012 Act but the broader aims can be achieved by allowing existing structures and organisations to develop in the appropriate way. In fact this is already happening in many parts of the country with Manchester as one example. People and relationships are more important than structures – structural change has never achieved what was intended.

The major difference is that the NHS Bill approach requires the closing down of hundreds of organisations and the creation of an unknown number of new ones based on a nationally defined model for regional and area bodies all with a largely appointed senior management. This is a much larger reorganisation than any undertaken so far and would be expensive, time consuming and a divergence from a focus on delivering and improving care. It would destabilise every part of the system and it is not necessary.

The Bill will not be passed. Even if it did the issues around implementation have never been thought through and there is no impact analysis or comparison of costs and benefits. Far more work is necessary to make any judgements about the true scale of change required.

The Secretary of State has never had the responsibility to PROVIDE the NHS. The word used in the 1948 Act is PROMOTE. Provision of a comprehensive NHS has always been limited by factors such as available resources and has never been absolute. What is required is a SoS with the powers to direct any part of the system – thus making it truly a single (albeit very complex) organisation able to make arrangements that are not covered by competition of procurement law.

The NHS has always had to make arrangements for services provided by small business based GPs, for ophthalmology, for pharmacy, for dentistry and services provided by private organisations, local authorities and voluntary bodies. The NHS has always treated some private patients. This requires some function of “commissioning” – it has always existed in the system and always will. The NHS has never provided all the services required and so some form of commissioning or even purchasing is necessary. What is required is proper democratic control over the planning/commissioning of services backed by proper openness and transparency.

There is no evidence that huge savings would be made by removing the market structures and this did not happen in Wales or Scotland, although over time some savings should be realised.

The way to prevent privatisation is to elect a government that does not do it. Passing an Act cannot in itself prevent privatisation, a new government could replace the legislation as the Tories did in 1990’s or else they could use guidance, regulation and the appointment of suitable people into key positions to drive outsourcing and privatisation as was done to local authorities during the 1980s. Legislation is Wales and Scotland does not make privatisation impossible but it would be very unlikely to happen.

Current developments around devolution around vanguards, success regimes, pathfinders and various other locally determined change programmes all rely on some flexibility over local structures – none could fit within the rigid structures of the NHS Bill. This would be yet another source of major disorganisation if the Bill passed.

The Bill is very weak on public and patient involvement, on regulation and on opening up structures to any form of genuine democratic accountability – perhaps because these are features that did not exist in the 1970s.

The Bill does not allow for there to be public bodies which only provide services as for example with the Trusts in Wales. Breaking up major teaching hospitals and reforming them somehow into some other structures under different management would be hugely complex, disruptive and contested. It is not necessary; there should be some bodies which are providers of services and some of these will be major public bodies. They will be involved in planning but there will be a requirement for some form of commissioning and some separation of this function from the delivery function is both valuable and necessary.

The SHA polices developed over some years provide a better framework for solutions than the NHS Bill and we should continue to develop our policies as we have agreed through the process agreed by Central Council. Supporting the Bill as opposed to merely sympathy with some of its aims negates much of the work done so far.

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3 Comments

  1. This article by the SHA’s Secretary-elect is written from a parallel universe, where devolution and Simon Stevens Five Year Plan is great, and everything develops ‘in an appropriate way’, everything that happened in the NHS prior to 2010 was great, and all that’s needed is some minor tinkering to undo a few bits of the Lansley Act.
    In reality, now hapless NHS staff go through reorganisations every 2-3 years as their services are tendered, and the UnitedHealth man in charge of our NHS has even bigger reorganisations up his sleeve, with a second £20bn savings plan that everyone says is impossible, and government ministers with plans for cutting another half of hospital beds and looking at charging, as the only way to square the circle and free up enough cash. While politicians think the unthinkable (and their advisors suggest ways of redefining what ‘the NHS’ really is (no longer comprehensive, no longer a bed, etc) so that they can charge for it), or ways of fragmenting it and ‘devolving’ it further so that the politicians in westminster can shirk the blame for all of this…
    This all happened of course as a result of the Lansley Act on TOP of the marketising Milburn/Blair/Stevens ‘reforms’ like PFI etc (that the SHA largely supported), and now Blair advisor Stevens back from his stint as UnitedHealth VP and running the NHS.
    So, unfortunately, minor tinkering really isn’t going to fix this. The NHS bill might not be perfect yet but it is the most serious attempt to date to find a way back to sanity, out of this expensive market mess, and it’s GREAT to see so many NHS campaigners united in their support for it.
    And it’s depressing to see the ‘Socialist’ health association so sanguine about the massive shift away from our interests, so keen to ignore the estimated tens of billions to fund the massively inefficient and expensive internal and external market that allows the private sector to get a look in. (incidentally, despite irwin and david cameron’s assertions, scotland and wales, who’ve largely scrapped market, DO get better results, per pound spent per head, weighted for socio-economic factors). and let’s not compare doctors to corporations, that old chestnut that is always used by the right but sits ill on a supposedly ‘socialist’ site. they’re completely different – as blair knew when he introduced the new doctors contract that allowed, for the first time, non-doctors (ie Virgin et al) to run GP practices.
    Those of us who live in the real world know that, quite simply, the NHS cannot go on like this. Ask patients, frontline staff, god, even ask the NHS bigwigs! The question isn’t ‘restructure or no restructure’, it’s ‘what kind of restructure’. The SHA has defended private sector encroachment on the NHS for years, regrettably (using the same daft arguments as the out ad out right, eg GPs=corporate bodies like Virgin)

  2. well said Caroline. agree totally with you.

  3. rotzeichen says:

    Irwin the problem is exactly structure, Lansley’s NHS speaks for itself, the NHS is just a logo, the commissioners outsource health care to “any qualified provider”, the secret is in the name.

    Here is what the KIng’s Fund says:

    In general, the issues that cause concern in health care are different from those raised by privatisation in other industries which focus on the sell-off of state assets. For the NHS the focus has been instead on outsourcing – giving contracts to the private sector to run NHS services.

    The involvement of private sector providers

    The Health and Social Care Act 2012 did not begin the involvement of private sector providers in the provision of NHS services – both the Blair and Brown Labour governments used private providers to increase patient choice and competition as part of their reform programme. However, the 2012 Act did extend a market-based approach to the NHS, emphasising a diverse provider market, competition and patient choice as ways of improving health care. The Act clarified the role of the competition authorities in relation to health care and that procurement decisions in the NHS are open to scrutiny and challenge, not just from private providers but from NHS providers too.

    Any Qualified Provider

    Any Qualified Provider (AQP) was a government policy intended to encourage all NHS, private, third sector or social enterprise health service providers to compete for contracts on an equal footing. It required clinical commissioning groups (CCGs) to put in place arrangements for certain services where patients could choose treatment from a range of providers who must all be licensed by the Care Quality Commission. The Department of Health put mandatory requirements in place until 2012/13 that all commissioners open a small number of services on this basis. However recent reports indicate limited enthusiasm for this approach at national level and patchy use of it at a local level. There are no requirements for commissioners to use AQP for services in 2013/14 or 2014/15 and 77 of the 183 CCGs did not open any services to AQP approach in 2013/14.

    What is spent on private sector providers?

    A range of other non-NHS providers provide health services, including social enterprises, local authorities, charities and community interest companies. It is difficult to determine exactly what is spent on private sector providers, as opposed to other non-NHS providers, particularly as some contracts for services are let to consortia that may include NHS providers, voluntary sector organisations and private providers. Overall, the Department of Health’s annual accounts suggest some £10 billion of the total NHS budget of £113 billion is spent on care from non-NHS providers (not including dentistry, medicines or general practice). The BBC reported that in 2013/14 £6.5 billion of that £10 billion was spent on private sector providers.

    Analysis of the Department of Health’s published accounts show that between 2012/13 and 2013/14 there was a 6.74 per cent growth in real terms on non-NHS providers, compared to 4.26 per cent growth in the previous year and 1.44 per cent the year before that. However, it is not possible to determine from the published accounts what proportion of this is spend on private sector providers as opposed to other types of providers. It also appears that a change in the way the accounts were reported in 2013/14 (to include spending by foundation trusts on services to be provided by non-NHS providers) accounted for most of the increase in that year.

    Other evidence shows that spend on non-NHS provision of health care has increased in some areas more than others.
    The rate of spending on non-NHS providers of acute care has slowed, with commissioners spending about £14 million less in real terms on non-NHS providers in 2012/13 compared to 2011/12.
    The proportion (by value) of community health services provided by the private sector increased from 12 per cent in 2010/11 to 18 per cent in 2012/13.
    Spending on private sector mental health service providers (mainly in-patient care) increased by 12 per cent (£126 million) between 2010/11 and 2012/13, while spending on mental health services provided by NHS bodies fell by 2.5 per cent in real terms (£17 million) over the same period.

    Some evidence shows that private providers have been more successful than NHS providers in winning contracts put out to tender, particularly in community services and diagnostics, but the value of these contracts is relatively small. A recent study by the British Medical Journal also found that one-third of the contracts to provide NHS clinical services awarded in the year from April 2013 were won by private providers, but the value of these contracts was only 5 per cent of the total value of all contracts awarded.

    Some very large contracts, particularly ‘prime provider’ contracts, have attracted particular attention. For example, in Staffordshire, CCGs are seeking bids for a 10-year contract worth £1.2 billion for cancer and end-of-life care, which – although not finalised at the time of writing – looks likely to have significant involvement of private sector providers.

    Franchising to private sector operators

    Only one NHS hospital, Hinchingbrooke Health Care NHS Trust, was franchised to a private sector operator, Circle, in a process initiated before the 2010 election, but in January 2015 Circle announced that it intended to hand management of Hinchingbrooke back to the NHS following financial pressures and a critical CQC inspection report that resulted in Hinchingbrooke being put into special measures. Further management franchises by private sector providers seem unlikely in the short term, in part because the significant financial challenges facing the NHS that make franchise arrangements less attractive to non-NHS providers.

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