From the West Midlands Socialist Health Association, January 2011

The Health Bill is a top down reorganisation of the NHS that no one expected and that even runs counter to the Coalition Agreement. Neither of the Coalition parties’ manifestos proposed a major reorganisation of the NHS. Nor did the formal Coalition Agreement which, in fact, was explicit that there would be “no more top down reorganisations”.The Government has nevertheless issued a Health White Paper, Liberating the NHS, which proposes just that.  So what does this mean for the NHS and the patients who depend on it?  What are the potential pitfalls?  And how could they be avoided?

Major disruption and uncertainty at a time when the NHS needs stability and direction

The Coalition government plans to abolish Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) and hand over most NHS funding (some £80bn a year) to consortia of GPs.  PCTs were only set up in 2002 and are already demonstrating their ability to ensure that the local services they provide or commission are well matched with the specific needs of local people.  GP consortia will be an unknown quantity –introduced at a time when the NHS is coming under mounting financial pressure.

Far from “Liberating the NHS”, these reforms will impose management and financial responsibilities on groups of hard pressed GPs who need to focus their time and energy on delivering high quality clinical care to their patients.  Even if such a monumental change in the way the NHS is run at local level were inherently desirable, past experience demonstrates that reorganisation brings major costs – not only in money, but in disruption of services to the public.

Few disagree with the idea of GPs playing a key role in commissioning services.  But do we need the whole architecture of the NHS swept away to enable them to do that?

Growing doubts about the wisdom of such radical change based on unproven concepts.

Alarm at the scale and pace of the organisational changes about to envelop the NHS is mounting in many quarters, including not only senior figures within the coalition but also leading voices amongst the GPs themselves, who are supposed to be taking up the reins of power.

Consultation on the proposals is now over.  Many doubts and caveats have been expressed across a wide spectrum of opinion.  However, Lansley is expected to press ahead regardless.  Indeed, the Department of Health has begun to make changes in advance of Parliamentary approval, such is the seemingly unstoppable power of this political steamroller. But there are telltale signs of nervousness creeping in among other key players at government level.  Some see chaos ahead, and some fear that Lansley is possibly not the safe pair of hands he was presumed to be when he was given the vitally important Health portfolio. Cracks in the wall?  Perhaps.  But let’s not count on it.

Why take such big risks with the NHS now?   Is it accidental or a deliberate plunge into chaos and market-driven ideology?

There are worrying hints that the creation of chaos alluded to by some Cabinet members is deliberate rather than accidental, and is part of the wider agenda of Tory ‘shock troops’.  Nick Boles, the MP for Grantham (a neighbouring constituency to Andrew Lansley’s), and a close associate of David Cameron, advocates chaos as the essential first stage in bringing about radical change towards the ‘Big Society’.  In Health, Education and Local Government, the Secretaries of State seem to be taking him literally.

Down at the coal face, rising NHS waiting lists might well be seen as a market opportunity by private healthcare providers.

So what’s wrong with Lansley’s reforms?  And what are the biggest risks to the NHS?

Risk 1: Privatisation of commissioning and privatisation of services?

Currently, there are some 153 PCTs serving populations of, on average, about 400,000 people. It’s expected that at first there will be a bigger number of GP consortia taking over.  Yet they’ll be doing this with reduced budgets for running what is by any standards a complex operation.  They’ll need help.  They’re not managers.  First and foremost, they’re doctors.  But they’ll be required under the new system to negotiate major contracts with powerful Foundation Trusts providing acute hospital services.

So where will the help come from?  In some cases, ex-PCT staff.  But watch out for the large private consultancies encircling the consortia in anticipation.  By the end of this experiment, the private sector could be playing a major role in shaping the way NHS services are commissioned. As Tory MP and former GP Sarah Wollaston points out, PCTs are being disbanded just when they are most needed to advise GP consortia.  Specifically, she warns: “We must ensure that the best managers are retained and feel valued rather than derided.  If they all disappeared and GP commissioners had to rely on private sector commissioning, it could start to look like privatisation.”

In this scenario, don’t be surprised if in the next five years we begin to see an increasingly large slice of the NHS cake being divided up among private hospitals, private clinics and private treatment centres.  Sarah Wollaston might just have put her finger on the biggest threat to the existence of the NHS since it was formed in 1948.

The NHS is poised to become a system driven by the ‘markets are best’ philosophy, not a planned service.  Is that what people want, or voted for?

Risk 2: Ministers assuming power without responsibility?

A National Commissioning Board will be established at arm’s length from the Department of Health.  The NCB will be to be responsible for running the NHS within overall policy guidelines, strategy and annual financial allocations from Government.

Ministers will undoubtedly seek to hide behind the NCB’s independent ‘quango’ status.  Don’t be surprised to hear Ministerial statements at the dispatch box that deflect criticism and questions from themselves to the NCB.  “It wasn’t our decision” will become a familiar refrain.

Risk 3:  Massive centralisation of power and control?

The NCB will hold all contracts with local GPs, dentists, pharmacists and opticians providing primary care services.  It will also be expected to carry out a whole raft of functions currently managed by PCTs within national guidelines.  In this way, power and control will have been massively centralised.

Even if the NCB decides it needs local offices, perhaps at regional or sub-regional level, it will not be a public authority in the sense that a PCT is a public body with responsibilities to its local community.  Power without accountability could easily become the order of the day.

Don’t be surprised if the practical problems of running the NHS from Whitehall force the NCB regional offices to take on more and more tasks and, inevitably, more and more staff.  Where will that leave Lansley’s plans for radical reductions in NHS management costs?

It’s hard to find the problem Lansley is trying to fix. Under Labour, the NHS improved its performance and benefited from massive investment.

If NHS performance had been falling, Lansley would have a better argument for radical change.  But just what is the problem he’s trying to fix?   Under Labour, there was not only major investment in additional clinical staff and facilities but a huge improvement in the quality of services provided. Waiting times have come right down.  Life expectancy has increased.  Clinical outcomes are better.  There is greater choice for patients about where, when and how to be treated.  More emphasis is given to prevention and health promotion, with many thousands of people having taken advantage of advice and support on healthier living.

Health expenditure up as a proportion of GDP

The ambition of the Labour government was to raise health expenditure as a proportion of GDP to a similar level to that achieved elsewhere in Europe, while at the same time keeping administration costs as low as possible. Britain is still a couple of points below its European comparators and spends significantly less than the USA, but in terms of outcomes the turnaround since 1997 is remarkable. The independent American body, the Commonwealth Fund, drawing on a survey of over 19.000 people in 11 countries, judges the UK to be foremost in terms of fair access to high quality health care.  Only Switzerland is judged to have a better health care system for its whole population.

Examples of NHS improvements in Birmingham and neighbouring areas

In Birmingham and neighbouring areas, there is striking physical evidence of Labour’s investment in new and improved facilities:

  • In the south of the city there are 12 new Primary Care Centre buildings as well as a new GP Practice and a new GP-led Walk-In Centre.
  • The state of the art Queen Elisabeth Hospital is the first new hospital in the City since 1938, and there are impressive new facilities for mental health treatment at the Zinnia Centre (Showell Green Rd), Moseley Hall, and the Barberry Centre (QE Medical Campus).
  • The Right Care Right Here programme in Heart of Birmingham and Sandwell is pioneering the move of services from hospital to local communities, and across Birmingham there are successful programmes for tele-health care and the support of people with long term conditions in their own homes.

Is there anything good about the “Liberating the NHS” White Paper?

Getting GPs more involved in commissioning services from hospitals and other care providers is to be welcomed in principle.  But PCTs had moved quite far in this direction.  So why smash up the whole system and try to turn GPs into managers?  Although the much respected Royal College of GPs initially welcomed the White Paper, its new president is expressing concerns about the responsibilities being thrust on to doctors at a time of serious constraints on resources.

Many people in local authorities welcome the idea of taking on responsibilities for public health – which rested in local government before a previous Tory government removed them in 1974.  This may open up opportunities for greater integration of health and social care in tackling issues such as delayed hospital discharges, aids and adaptations, domiciliary support, re-ablement, and services for people with mental health problems and learning disabilities.  But will councils be given the money to do the job?  That’s quite another question.

Should the White Paper be opposed?

We think it should be opposed – on a number of counts:

  1. COMPLEXITY: The proposed NHS structure will be more complex than ever, making it more difficult to improve productivity and quality.
  2. EXPERIMENTATION AND RISKS: This is a giant experiment based on little or no evidence.  There is no equivalent half-managed, half-regulated structure anywhere to use as a model or benchmark.  The risks being taken with the NHS, and ultimately the nation’s health, are huge.
  3. COSTS: The changes could ultimately lead to massive cost increases in overheads.
  4. CONTROL: There’s a major risk of greater centralisation of control – the very opposite of what the government purports to believe in.
  5. POTENTIAL POSTCODE LOTTERIES AND INCREASING INEQUALITIES:    The disappearance of Strategic Health Authorities and Primary Care Trusts – the basic NHS planning infrastructure – could lead to greater variations in services across thecountry and to a widening of existing health inequalities.

Further information

If you would like further information about the possible effects of the Coalition’s White Paper on health in the West Midlands, please contact Alan Wenban-Smith, Chair, West Midlands Socialist Health Association.  Email: alanwenbansmith@pobox.com

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