NHS Liberation

NHS reorganisation

NHS Liberation first came to light through well informed rumours that the DH was working flat out on a massive Health Bill, first estimated to be over 400 clauses.  The first bill was for softening up and was part of a two parliamentary terms strategy.  A small minority at that stage were warning about it – whilst many others were in near rapture about the rhetoric of clinicians in charge of the money, removing top down bureaucracy and putting patients first.

Anyway we said then in 2010 what the real scenario was and Labour and a few trade unions started the opposition – being joined far too late by the medical establishment.

It was never a scenario ending in a US style system – nobody wants that (probably including most Americans).  But it was a plan to end once and for all the Bevanite socialist NHS. To boldly go where even Thatcher feared to go – to repeat the huge successes of privatisation of the utilities.  It was to deal with the NHS ignoring social care, public health, inequality and the determinants of poor health.  It was to complete a journey started in the late 1980’s to move to a regulated market for our healthcare.

Key aims were to shift provision to private providers and to give purchasing power to either people or their insurance companies.  Whilst healthcare remained free that would eventually only apply through means testing.

The steps along the way were likely to be:-

  • rubbishing NHS providers
  • ignoring all problems in social care (provision is already in private hands and access is means tested)
  • removing any genuine political accountability for the NHS blur the notion of entitlement
  • increasing the use of private providers (see social care!)
  • using Compulsory Competitive Tendering at every opportunity to increase % of private provision (pretending this was the fault of the EU)
  • funding providers through market means such as payment by volume, with defined pricing – no security through block funding
  • allowing top ups and co-payments for buying “better” services (two tier NHS)
  • eliminating Strategic Health Authorities and any other body that might have a strategic view (like killing off LEAs)
  • making residual NHS providers behave as if they were private businesses, blurring edges through increasing NHS provision for private patients
  • using Any Qualified Provider to stimulate idea of consumer choice of provider
  • using competition law and other legal obstacles to prevent emergence of strategic providers
  • using insolvency law to allow break up or sell-off of struggling NHS providers (as with failing schools having to become academies)
  • extending the scope of personal budgets move to calculate indicative budgets for everyone (see Care Bill) – (see enforced move to personal budgets for continuing healthcare)
  • marginalising commissioning to residual activities – consumer choice dominates – like LEAs
  • buying off resistance from GPs and consultants – their role stays same
  • giving tax relief and other incentives to private purchase of care
  • stimulating private insurance market to buy care (see Care Bill)
  • merging personal budgets into benefits system (as with housing costs) then means testing

To varying degrees we are seeing all of this going on.  In almost every care it has not gone well!

On the other hand we see stuff that worked against the “Plan”:-

  • the coalition – the original intentions were compromised
  • the actual shambles of the Health & Social Care Act – incoherent and ineffective and unravelling
  • the shambles around regulation – grave doubts it will ever work
  • the enforced attention onto real issues for example around social care
  • the return (big time) of political micro management
  • the huge dislocation caused by the reorganisation, and the threats to service delivery
  • the rise of integration and the tension with market fragmentation
  • the emergence of the Health and Wellbeing Boards and the suggestion of some strategic or planned approach
  • the failures around actually developing the framework like extending Payment by Results and tariff
  • and the obvious inability of the system to be able to design and build the new information architecture to support big changes
  • the lack of interest from insurers (and only muted interest from private providers as no money in system)
  • the obvious signs of a lack of public support for the big changes and continuing local guerrilla warfare over even minor changes
  • the rise of relevance of public and patient involvement.

By 2015 the care system will be a total mess and solutions will not be found through extending a regulated market and competition. We have set out elsewhere that repeal of the Health & Social Care Act is a necessary but far from sufficient requirement.  We have also argued that what would be required is a 10 year plan for care – this time a plan that is actually published openly (as opposed to a conspiracy).

The imperatives for change remain:-

  • radical and expensive changes are need in the provision of social care
  • the NHS as a system is not fit for purpose – it does not value accountability, shared decision making, community development or public and patient involvement
  • the NHS is still isolated from the rest of public services and has no democratic legitimacy
  • the distribution of NHS services and facilities is not aligned to need (although every reconfiguration is contested!)
  • the allocation of resources is not led by public health or by considering the determinants of poor health
  • there can no longer be a cultural and organisational divide between social, mental and physical health (or even between primary, community and secondary health care).

We have to believe that the NHS will not be irrevocably damaged by 2015 and do what we can to fight against any fragmentation and privatisation.

But more than that we desperately do need a compelling vision of a care system that we would all approve of, but one that we can realistically campaign for and see delivered in perhaps one generation.

We find it easy to describe what would be better but are very poor at describing how we get there from where we are now – when money is tight, reorganisation on any scale is impossible, public distrust is endemic and many of the best people have left the system.

And just to round off:

If we genuinely want a universal comprehensive care system – free at the point of need – then we have to pay for it.  That will mean extra taxation of some kind and an increase in the %of GDP that we as a nation spend on care.  There are no magic solutions.