Reflections on the NHS in England

The NHS in England is under threat from the pro market lobbyists and under great strain due to financial pressures. It’s not a happy story.

Shortly after the 2010 election rumours began about a monster Health Bill – 400 clauses and designed for change over 2 terms. Despite lies in the coalition agreement about no reorganisation of the NHS by 2012 we had the Act.

The Lansley blueprint to bring in a regulated market for healthcare, like the utilities, began with a white paper promising things which fooled many who should have known better, into vague support. The SHA was in the forefront of opposition pointing out the dark side, but only the leading health unions and Labour were openly opposed. The pretence that somehow the Tory proposals were some kind of continuation of existing policies was rapidly refuted. This was making competition and markets the strategy for healthcare not about the occasional and managed use of competition if appropriate.

The Bill was shorter than expected but was obviously about moving to a market. Labour fought the Bill line by line in Commons and Lords to no avail. Many amendments were made, making the result virtually unworkable, but the essence of the market was fixed into Part 3. By the time the Bill became an Act the opposition was virtually unanimous. It was too late.

The disaster might have been prevented had the GPs collectively signalled they would not accept the changes they had to be involved with or if the Royal Colleges had collectively signalled their opposition. It didn’t happen. The LibDems ensured the Act was passed although they never got the payback they were promised in terms of constitutional changes.

The Act set up the structures and mechanisms by which healthcare moves to a market. It reinforced the commissioner/provider split with Clinical Commissioning Groups (led by GPs) and set out the architecture for greater competition amongst providers. It removed some of the political levers and downgraded the role of the Secretary of State; and it removed the idea of any local strategic leadership – not necessary in a market. Monitor was set up to be the economic regulator, fixing the prices and stamping out any anti-competitive behaviour.

The Act included, as an afterthought, Health and Wellbeing Boards to be vehicles for local integration of care services, and Health Watch as some king of body to facilitate public and patient involvement.

The greatest threat came from the pressure on commissioners to use competitive tendering . This was a one way process as it meant NHS providers could only diminish in terms of their share of the “market”. There is no doubt that the Act opens up greater opportunities for private providers to have access to NHS provision.

The Act fundamentally changed the NHS and paved the way for the end of the NHS as provider, for co-payments, top up fees and even the possibility of an insurance based system.

Which is bad enough, but this massive and expensive reorganisation took place against the background of severe cuts in funding levels forcing the NHS to try to find savings on a scale never achieved before, anywhere. Cuts in budgets for social care have magnified the problems. Tory controlled communications attacked the NHS at every opportunity, distorting and exaggerating know issues.
Implementation of the changes has been patchy as it becomes clear that the original Lansley model has been quietly dropped and some pragmatism is coming into play. You would struggle to find any open supporters of the market, competition, privatisation model. There is already talk of amending some of the worst (unintended?) aspects. It is still early to judge the true impact of the Act but the negative impact of the combination of structural changes and funding cuts is becoming clearer as many NHS providers are now either officially or just obviously in financial difficulty. They are threatened with various forms of intervention and “failure regimes” which are likely to involve offering private providers and the leading private sector management consultancies rich pickings.
Some of the provisions in the Act around public and patient involvement have some positive aspects but there is little sign yet of activists engaging in the new structures.

Some CCGs are virtually ignoring the regulations and are not planning to competitively tender everything. Some CCGs got involved in tendering and make a mess of it! In a number of places local groups and trade unions are actively opposing tendering activity – with some success.

For the SHA in England the position has always been total opposition to the Act and to the whole idea of a market of any kind for healthcare. We have strongly lobbied the Labour Party and believe that our policy is quite well aligned to that being advocated by Andy Burnham and the Labour Team.

If the Tories get a majority at the next election in 2015 they can complete their plan to dismantle our NHS, everything is in place to do it.

If Labour wins then they are committed to repeal of the Act. They will remove all the market structures (in Part 3 of the Act) and restore the political and legal accountability of the Secretary of State. They will do this in a way which does not trigger yet another wasteful and destabilising set of structural changes. The SHA is working to find the best ways to bring this about as we need workable answers not just slogans and rhetoric.

Richard Bourne is the immediate past Chair of the UK Socialist Health Association

This article first appeared in Healthier Scotland – The Journal Published by Socialist Health Association Scotland March 2014