How “comprehensive” is the NHS? Or “Something’s gotta give”?

Marilyn Monroe
Marilyn Monroe

Many in the discussion would wish you to concentrate on the phrase, “free-at-the-point-of-use”. This is the idea that you a patient does not pay for any treatment.

Many also do not understand the Health and Social Care Act (2012). There are many in the social media at large who feel that the NHS needs to face change in improving the service, and indeed point to crises within the NHS as examples of a failing service. It is critical that the NHS can learn from its mistakes, in terms of its operations, strategy and leadership. However, the Act’s primary purpose is not about that. I simply do not understand why the media, and notably the BBC, have been ‘asleep on the job’, in explaining what these £2bn reforms were about. The most common explanation is that the Act is incomprehensible. As a law student, it is perfectly comprehensible, but I would say that? The Act abolishes a number of important national authorities, such as the National Patient Safety Agency and the Health Protection Authority, but it legislates for a much greater number of private companies to do NHS functions in the name of the NHS. This means that ‘market forces’ can lead to distortions in provisions of healthcare, determined by the individual business plans of the companies involved. It is therefore a “supplier-led market”. In the high street, neoliberal forces have seen less profitable sectors such as immigration, housing and asylum, struggling compared to their City counterparts, corporate finance and the such like. Therefore, the critical issue is how “comprehensive” the NHS is.

On top of this, it is impossible to ignore the impact of the drive for ‘efficiency savings’. In 2009, Sir David Nicholson was reported of requiring such savings as below:

NHS trusts will have to deliver between £15 billion and £20 billion in efficiency savings over three years from 2011 to 2014, David Nicholson, the NHS chief executive, told health service finance directors in a speech delivered behind closed doors.

The steep cuts would be equivalent to up to six per cent of the current NHS budget.

Health trusts which fail to deliver the required savings could face tough new penalties following a review by the Department of Health of its enforcement regime.

The definition of “comprehensive” in the Oxford English Dictionary is indeed a useful starting point, essentially described as “including or dealing with all or nearly all elements or aspects of something“:


Definition of "comprehensive" in the OED
Definition of “comprehensive” in the OED

“Comprehensive” therefore means for most people “all” or “nearly all”, and it’s a matter of interpretation what “nearly” is. This “nearly” aspect has been a slow-burn in policy, for example: “Labour’s national policy forum will debate a draft document on the NHS which contains references to a “largely” comprehensive and “overwhelmingly” free service.” In March 2011, the NHS published its NHS Constitution, and a leading guiding principle is:

The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief

This non-discriminatory aspect of provision of healthcare therefore emphasises equality.

It is therefore disingenious that a campaigning issue that individuals maintain that, after implementation of these costly reforms, that the NHS will still be ‘free-at-the-point-of-use’, as that ignores the comprehensive point. Colin Leys in the Guardian has already highlighted this as an issue in the Guardian:

Under the bill the range of what is available for free seems certain to contract further. Commissioning groups will have fixed budgets. The for-profit “support organisations” that are being lined up to do most of the commissioning for them will have a strong incentive to limit costs, and therefore the treatments to be paid for. CCGs also look likely to be free to decide that some treatments recommended by hospital specialists are “unreasonably” expensive, and refuse to pay for them, as health maintenance organisations do in the US.

A core of free NHS services will remain, but they will be of declining quality, because for-profit providers will cherry-pick the most profitable services. NHS hospitals will be left with the more costly work, so staffing levels and standards of care will be forced down and waiting times will get longer. To be sure of getting good healthcare people will increasingly take out private insurance, if they can afford it. At first most people will take out the cheaper insurance plans now on offer that cover just what is no longer free from the NHS, but gradually insurance for most forms of care will become normal. The poor will be left with a limited package of free services of lower quality.

What is available on the NHS should be determined nationally, in a transparent and democratic way, not by unelected local bodies. The bill will allow the secretary of state to deny responsibility when good, comprehensive, free care has become a thing of the past.

There are indications that services are being “scaled back”. For example, there have latterly been reports of impact on hearing services, for example:

NHS hearing services are being scaled back in England, an investigation by campaigners suggests.

Data obtained by Action on Hearing Loss from 128 hospitals found more than 40% had seen cuts in the past 18 months.

In particular, the study found evidence of rises in waiting times and reductions in follow-up care.

The report is the latest in a growing number to have suggested front-line care is being rationed as the health service struggles with finances.

The NHS is in the middle of a £20bn five-year savings drive.

The political question is, of course, whether the public accepts the need to ‘scale back’ these services and doesn’t care about the service being entirely comprehensive; or whether Labour (or indeed any party) should simply give up on an inspiration for totality in the service. A film once starred Marilyn Monroe entitled “Something’s Gotta Give”, and now that the first major step has been taken in ‘liberalising’ the NHS to any qualified provider, it is perhaps more necessary than ever to admit there is no guarantee at all on the NHS provision being close to “comprehensive”, unless the NHS Commissioning Board gives clear and precise details which services have been cut and where. This is going to be increasingly significant as a mature discussion about rationing gathers momentum too.

Above all, it seems now essential that local respondents are allowed to offer feedback into this clinical decision process, for example as demonstrated recently in the Lewisham situation, otherwise localism is a complete farce.