30th April 2013
Ian Goley: One of the main questions that has come up in the literature review, when people say that they want to defend the NHS from the NHS reforms, what is the NHS?
Clare Gerada: That is a very very very good question. And it’s such a good question because nobody ever asks it, and I ask it because people talk about “the NHS” and I say what do you mean. They usually say it’s a service made up of hospitals, doctors and nurses that are free at the point of use. It isn’t, the NHS is a system of distributing resources according to need, not according to want. So it’s a distribution system, amongst other things; so we also have a National Health Service that also provides care that is free at the point of use, that is held together by systems of governance, employment, structures that underpin delivering this money to where it’s required. That’s what it is, it’s nothing more and nothing less. What the NHS is becoming – it’s also a social solidarity which we all adhere to because we know that if we’re in a queue we will get the care that we need, but if we’re in a rush and we need it we’ll get it sooner. So that’s what it is.
What it will become is a system of payment only. It will become a system whereby the money that the state allocates will be called NHS. Because what else is it. I mean if you take away the distribution of resources, then what is the NHS? It’s nothing more than the Medicare, Medicaid – it’s not a fair distribution of resources. So that’s what the NHS is to me.
IG: So when you say it will become
CG: Well it already is
IG: Is that the 1st of April, or
CG: Yes. I mean one is the duty to provide. So, up until now the Secretary of State for Health has had a duty to provide a comprehensive service. Now he just has to promote a comprehensive health service. The other thing is that what we’re already getting in the marketised health system is we’re getting lopsided care; where the classic is, a recent one of Specsavers advertising for digital hearing aids: now, you could say it’s addressing an unmet need. Actually, it isn’t. What it’s doing is it’s shifting resources away from where they’re needed into a specific area called digital hearing aids. What it will become is like with all marketised systems: money will be the determinant. It already is with PFI, even within the NHS system, but it will become increasingly that. So what will be provided will be what can make money. So you’ll get, the classics will be radiology, intervention with radiology, dermatology, orthopaedics, ophthalmology, stuff that’s high volume, low cost that you can make money from.
IG: So the example of using Specsavers, or even at the moment, before these reforms, the GP would give you a prescription and you would in most circumstances take that to a privately run pharmacy
CG: Yes, Bevan introduced some co-payments, but the co-payments had to be determined through Parliament, so you’re talking about something slightly different. Pharmacies, yes, are private, and people often say GPs are private. If you mean “private” that money exchanges hands, not it doesn’t, even though the pharmacist has to ask for money, for the medicine, that’s not his gift, that’s laid down by government. So you’re not paying the pharmacist for his service; you’re paying the state as a co-payment, which has been determined through an Act of Parliament. The same with GPs, you don’t come and give the GP your credit card, but the example with Specsavers, is that… I thought you were going to say that Specsavers already provided NHS provision; they did. But what’s happening now is it’s going to be exploded, and already people are getting leaflets through their door “go to Specsavers and ask your GP to refer you for digital hearing aids”. You’re shifting resources; not according to need, but according to want, and the power of the market. The NHS was a system that was beautifully held together, partly through the human beings within it, but partly through that the fact the way it was set up, there was no incentive whatsoever for me to refer you to a hospital. I didn’t get a kickback. Equally the hospital didn’t get a kickback for keeping you in any longer, or doing any more tests. This is gradually going to shift. And what will happen gradually will be as I can now earn more money privately, there’s going to be a mix and match of NHS and state, and NHS and private going alongside which you never had, ever. And there’s going to be a blurring of what the NHS is, because the NHS in the end is just going to be a system of payment. That’s it. It’s going to be a state insurance system.
IG: So, coming on more to the reforms, there is the argument that “anyone who claims to have followed the NHS reforms, hasn’t been following the debate”. Is that something that you would agree with?
CG: I think very few people have followed it. I mean, even now, people who should know better have completely missed the point. You asked the most important question at the start: “what is the NHS?” They don’t ask that to start, they assume. So when they say that the NHS is and the NHS is that, I say you’ve all got it wrong; Mid-Staffs isn’t the NHS, it’s a system within. It’s part of a system. The NHS is this fair distribution of resources. Yeah I don’t think many people did follow the reforms, and they were very complicated, they still are. Because they’re all tied up, not just in EU regulation but in US-EU regulation and in competition and commercial law. And in stuff that is so way above the heads of most people that it’s difficult to follow.
IG: So, what would be the most significant aspects of the reforms?
CG: For me, there’s three red lines: and again, unless you’ve read the reforms, they’re complicated. 1 is the system of resource allocation isn’t quite in the Bill, but it’s coming; the system of resource allocation is going to change from area based to individual. So again, if you think about your HMO, your insurance model, it would be your allocation for next year’s health – you, physically – would be on your last year’s activity, or on what the actuary sets, we’re going into insurance modelling. The other one is within these set of reforms there is the removal of traditional GP boundaries; again it’s in the secondary legislation, but you’ll be able to register anywhere. Now, people say that’s good through choice, but it then blows apart the GP serving their community; I’ll be able to advertise lock stock and barrel for the nice, fit young… And the third red line is the duty to provide, versus the duty to promote; the duty to promote has replaced the duty to provide. So that’s the third one. But there’s also all the legal structures that underpin distribution of resources fairly. But again, they’re very complicate; but those are the sorts of things that I think the reforms have done. They’ve denationalised the National Health Service.
IG: Does the role of GPs on the Clinical Commissioning Group…
CG: Well that’s irrelevant you see, because I don’t think GPs will be on CCGs much longer. We haven’t got any staff; we are reeling under the workload, and even if we did have staff, the legislation doesn’t dictate that GPs should be on the majority of the board. Most CCGs do not have GPs heading up the CCG, and as CCGs merge – which they will inevitably merge – you’ll get less and less clinical involvement; the clinical involvement will be in an advisory role. It’ll be more and more that the real power of a CCG will be in the CSUs, which are the engine room of the machinery of the monitoring, the data crunching, invoicing, the resource allocations, that’s where it will be.
IG: So you don’t think that competition, well, GPs involvement with competition through CCGs will be as prevalent? – as it’s otherwise made out to be?
CG: I don’t think GPs will be involved at all. I think this business about GPs and conflict of interest is irrelevant. I think it’s so miniscule, and it dwarfs in comparison to the conflicts of interest that many of our ministers have; it’s dwarfed. You know, McKesson [a large healthcare company] pay a retainer to Lord Carter [of Coles] of nearly a million pounds a year; he’s in charge of the competition commission – well, how much more conflict of interest [can you have] – so many of the Lords have serious conflicts of interest – so the fact that a GP owns a company where he might do a bit of dermatology on the side, is irrelevant.
IG: And so the argument that goes that the commissioner and the provider being the same?
CG: The split between the two?
IG: Yes
CG: Again I think it’s irrelevant; it’s a red herring. And I think actually, in many ways… You see, when we didn’t have perverse incentives, and when we didn’t have so much money involved in health – i.e. when we had the NHS – commissioners and providers should go arm in arm. I’m an expert in substance misuse – if I’m not there as a provider and a commissioner, what on earth… So no, I think it’s a red herring.
IG: In terms of the other reforms, so HealthWatch. Is that… [something you think will have an impact]?
CG: It will be the same… I mean I’m old enough now to have seen Community Health Councils, Links… it will go that route – it will be under-resourced.
IG: So it’s nothing new that’ll be anything too significant?
CG: No, it’s nothing
IG: And also the Nicholson Challenge. Do you think that the NHS reforms, through the Health and Social Care Act, mixed together with that [the Nicholson Challenge / QIPP] will… [that result in a negative situation for the NHS]?
CG: Well, we always said right at the start that having a reform so large you can see it from outer space alongside one of the biggest fiscal crises we face, is silly; at the very least. I mean, just think about your own life – what you don’t do is to suddenly rebuild your house when you haven’t got any money in the bank. So yeah!
IG: As I said, I’ve been looking at the Oregon Health Plan, which looked at explicit…
CG: rationing?
IG: Yeah, well that was the headlines associated with it. Looking at the literature, some would argue that there wasn’t that much rationing that took place
CG: No, it was just fertility treatment if I remember rightly? And neo-natal cots.
IG: Yes, but the principle of – the politics of that – that it got in effect the public debate…
CG: Yeah, I think that was very useful, yeah
IG: …about what healthcare should be provided
CG: And also what the cost of care is. Yeah, I mean, I think it would be quite useful for the public to get involved. But the public will always pick infertility treatment. Always. They will never pick cots, not in this country. But they should be picking cots. We’ve [got] NICE of course, so NICE does the Oregon for us on a day-to-day basis. So yeah, Oregon was a good, very good move. Didn’t change anything, but it gave us an example of if you ask the public, this is what they’d come up with.
IG: That’s interesting, because at the moment there’s a perception that implicit priority setting is apparent within the NHS. Although you have got the role of NICE where some elements do appear to be explicit.
CG: Yes, I think it’s a finely tuned machine, which is why the government meddling with it is a disaster beyond…
IG: So the status quo would be the preferred option?
CG: Yeah, I mean we’ve always rationed. GPs have always rationed; we’ve rationed with waiting lists; we’ve rationing with what you’re waiting. We’ve always rationed, but it was done in a way that was done with our eyes open and done involving the patients sometimes. Now it’s explicit rationing: now you cannot get your two eyes, you cannot get your two hips. And it’s done in again, in the machinery of the market, which I think makes it quite ugly. And puts mistrust into the system. Which is what I think is happening.
IG: Which is the negative element?
CG: Yeah
IG: So, just related to that, the NHS Constitution of 2009 defines the NHS as a comprehensive service
CG: Beautiful definition. It is something like ‘the NHS is owned by the people, for the people. It’s a lovely… You need to start your dissertation with that definition. Which has carried through in to the 2013 constitution. Have you seen it?…it’s
IG: Yeah
CG: …a beautiful, beautiful definition. It starts I think, ‘the NHS belongs to the people’… Sorry, what was the question?
IG: In terms of comprehensive care, has the NHS actually set out what it does provide? Do you think?
CG: If you read Allyson Pollock’s work, she sets out what it’s no longer going to provide. So immediate and necessary anti-natal care, so yes. It never has set out exactly what comprehensive care meant, but in a way…
IG: But, does it need to [set out the care it provides]?
CG: No, I don’t think it needed to. But now it’s the opposite; now Allyson [Pollock] sets out what it isn’t going to provide, which is more, the opposite.
IG: Just, lastly, in terms of, what is the end result for the NHS reforms? Because, depending upon who you, in terms of the academics, some would argue that if you look at the US reforms, that’s bringing it closer to the model of the NHS, even though it’s still the significant reliance on the insurer; and that the NHS reforms are going the other way.
CG: Yeah
IG: Is that [something you would agree with]?
CG: Yeah, well I think that’s a very good analogy. We are now heading much towards the United States system than the European system, which has a sort of modicum of distribution of resources based on area base, planning. Whereas we’re heading much more towards an individualised, free-for-all based, exactly that; with choice being at the centre. Which ‘choice’ means a market. The irony is that every health service is trying desperately to recreate an NHS, so with an integrated, primary-care led system. And we’re heading the opposite direction. Ironic isn’t it?
IG: [laughter] One other aspect of my dissertation is looking at local autonomy.
CG: Yes
IG: Will that…?
CG: No. I don’t think you’ll get local autonomy any more than local government is free to determine how much it charges its rents and rates, and what it can provide. I can’t see how you’re going to get local autonomy. I mean you might get a little bit of local autonomy for determination depend upon need. So a seaside town might do this, or Cambridge might have student services. But if you say local autonomy; that a local area decides not to … Really stark example: local area says we’re no longer going to fund 26 week neo-natal cots… Impossible. Impossible. [it will] Never happen. More, the worrying thing is then when they say we’re no longer going to provide obesity services to smokers, or sexual health services. But then that’s local government, and I do think moving some care to local government worries me, because you put politics into health and we know that when you put politics into health – real politics – you get disasters – look at the States and their abortion stuff.
IG: When you say ‘real politics’, that’s more party politics? – As opposed to elected representatives
CG: Yes, so more party politics, so today, the whole news is that prisoners aren’t going to have Sky TV. What if you said prisoners aren’t going to have access to condoms. You could use the same argument, and that’s what our worry has been; putting politics into health, where it has no place. And I think that moving it to local government puts it into health where it has no place. And I worry about that. I’m not so concerned: I don’t think local determination will happen with the big ticket issues though. Money will dictate. When you go to Chicago, they have the place with all the hospitals, they have more scanners than… Because scanners create income. They don’t need scanners. And all the hospitals are distributed at one end of town, because that’s where the rich people live. You don’t get hospitals at the other end of town. That’s what markets do.
IG: And just one, final question. There’s a quote where you’ve said about it [the NHS reforms] creating a budget airline.
CG: Yes, that was my 2010… Did you read the speech
IG: Yes
CG: Did you like it?
IG: Yeah. And the Department of Health response to that was effectively, ‘within the reforms everyone will be flying first class’.
CG: Do you think that’s true?
IG: [laughter]
CG: Go and look at the waits in A&E now. No they won’t be flying first class [laughter]. We’re already seeing queues develop. And, just picking up some of the news now, I haven’t looked at it, but there’s a big hint about increasing co-payments. And paying for care, more and more, which is what happens in social care. Everybody will not be flying first class. There will be those that can afford to top-up their NHS allocation of resources, who will get a better service. You will get better because you’re fit and well and you’ll top-up you bits and pieces because you’re not going to be ill. No, everybody won’t be [flying first class]… I would rather everybody flew economy, because then we all fly the same. Dentistry, look at dentistry, the idea that everybody in dentistry receives excellent teeth is crap, isn’t it.
CG: Is that alright?
IG: Yes, that’s excellent.
CG: Is that going to help you pass your dissertation?
IG: Yes. This is what I’m starting with [showing quote from NHS informational leaflet in 1948].
CG: You can see how the language changes can’t you. Fantastic. Have you just come down for today?
IG: Yes, I’m going to the British Library , because, as I said, doing it partly on the Oregon Health Plan, and books are quite difficult to find.
CG: So, your dissertation is on the reforms. So, presumably you’ve read as much as you can on Allyson Pollock, the BMJ articles, and Martin McKee, they’re very good. Well, good luck,
IG: Thank you
CG: And I wish you well with your research.
IG: Thank you, thanks for agreeing to an interview.
CG: Lovely, pleasure. Do you like our college?
IG: It’s very nice, yeah. How long has it been here?
CG: Well, this was the first place that the NHS was – Ministry of Health, so 1948. But we’ve been here about six months.
Ian has been working with us for the last year and this is part of his undergraduate dissertation submitted to the University of Sheffield.