Developing Labour Health Policy
Toynbee Hall 28 Commercial Street, London E1 6LS – nearest tube Aldgate East
10am – 3pm Saturday 2nd December 2006
The Labour Party National Policy Forum consultation document on health has been released, and this will be the basis for our discussions. Submissions are to be sent in by March 2007 to pip3.health@new.labour.org.uk. Anyone can send their comments, but we hope that a clear well argued submission from us will carry some weight.
With Prof Nick Bosanquet, Consultant Director of Reform and Dr Jacky Davis, Keep our NHS Public
Notes
rearranged to put points together, rather than as they were raised, reduce repetition and to make clearer what was meant
Nick Bosanquet: Where do we go from here?
The NHS was established with a military style central command structure which is no longer appropriate. Large public sector monopolies are no longer a popular way of providing services. The world has changed. Life expectancy has risen enormously. Society is much more diverse. The problem now is to provide care for people who in earlier times would not have survived, like the 60,000 people alive with kidney failure. Central planning has not been very successful in dealing with these challenges. Large amounts of extra money pumped into the NHS have provided disappointing results.
We have three levels of nationalisation – Funding, Resource allocation and Provision. Reform is in favour of continued funding through taxation (not in favour of an insurance system) but wants to see a more pluralistic system of service provision. An increase in funding to nearly 10% of GDP has led to an increase in costs – new hospitals and LIFT schemes. What we need is a patient driven high quality service. A pluralist approach, better communications and possibly more direct payments could deliver this. Pluralism has been a success in optical services. New providers have emerged, prices have fallen and there have been more choices of spectacles available for the poor since the service moved into the high street. Compare that with audiology services still inside the NHS, delivering a slow service and not responding the technical innovation. It has worked in pharmacies. Maybe we need a system whereby services complementary to the NHS can be provided.
There will always be rationing of services, but waiting times and queuing are a very unsatisfactory mechanism for doing it. We need mechanisms which encourage innovation. And now we need to separate service redesign from measures to reduce deficits. Alternative services need to be in place before existing services close.
Lots of new providers want to come in. Considering the money spent on the NHS waiting times are still too long, and we are seeing reductions in services and increases in costs. Centralised planning has not succeeded in shifting resources out of hospitals into community services. What we need to do is build up the power of patients and GPs. Already the NHS plan is out of date – we are building too many expensive new hospitals with inflexible PFI schemes. We have expanded our medical schools but there will not be sufficient jobs for all those who qualify.
Connecting for health will be an expensive failure because it is centrally planned and directed, it fails to build on existing IT developed by GPs. And it doesn’t have a financial component.
Wendy Savage: Nick spoke about evidence based policy and then mentioned the Adam Smith institute report of 1999 which showed reform was needed not more money but it is wrong to judge the NHS on results in 1999 at which point there was no extra money as New Labour had stuck to Tory spending plans. Expanding and developing services takes time and a stable environment. There have been several reorganisations which destabilize the NHS and are expensive. The government seems ideologically in favour of private rather than public services but is the private sector more efficient than the public sector? Did I mention recent health care commission report about private hospitals?
Most people when asked want a good local hospital service, not more choice. Forcing PCTs to buy up to 15% of services from private providers last year has contributed to deficits We need to establish community services before closing hospitals.
Doesn’t accept that there will be a shortage of jobs for new doctors.
25% of doctors on medical register come from overseas many of whom came in 50s and 60s and are due to retire soon. It is surely right that a rich country like the uk should train enough of its own population in medicine rather than poaching doctors from developing countries?
Government seems to dislike doctors. 30 year PFI contracts are not Good value for money 5 billion spent will cost 10 times that by end of contracts and locking hospitals into 30 year contracts whilst transferring services to community does not seem like ‘joined-up
Thinking’. The NHS in the past was a co-operative not a competitive Environment with very low administrative costs about 2% before Griffiths re-organisation in 1984. Now co-operation is obstructed by bureaucratic systems and administrative costs have risen considerably to an estimated 15%. Too much money is spent on managerial trappings and management consultants-last year almost as much on management consultants as all the hospital consultants in England. I have seen how Patricia Hewitt’s eyes lit up when an American inspired hospital orthopaedic centre modelled on a New York facility was mentioned at a conference but the USA is not a model we should be following 47 million uninsured, high administrative costs and fraud is endemic.
The NHS is not an industry it is a service and if the present changes continue it will end up as a logo with private companies providing the service and they have to provide profits for their shareholders. We do not want to regard the NHS as selling a product. In the past the NHS may have been unresponsive but this was more to do with insufficient staff-5 min consultation time for GPs for example and underfunding which has been present since the NHS began but it is a tragedy that for the first time that there is sufficient money it is being wasted on paying the private sector 11% extra money for doing operations whether or not they perform them and constant reorganisations. The consultation for Our Health Our Care Our Say was flawed because of the questions asked and the idea of a ‘patient-led NHS seems to owe more to spin than substance.
We need a halt to change and to let things settle. Deficit crisis this year is completely unnecessary. Gordon Brown floated the idea of an NHS board but it seems unlikely that with such a large proportion of GDP spent on health that the government would be willing to relinquish control although one problem is political interference.
General discussion:
Most of the population do not understand the present situation of the NHS. Much NHS consultation is phoney and ineffective. Choice is always a mirage, always limited by resources and the choices on offer are not those we want.
This discussion is really about England. Different paths are being followed in other parts of the UK and they merit discussion.
How can the NHS respond to patients and to new possibilities without involving the private sector? In the past the NHS was cheap but not responsive.
We should not separate primary from secondary care. We need better mechanisms to drive up standards in General Practice, and we need to provide incentives to providers to develop innovative cost effective care.
The NHS has sometimes delivered a better service to the middle classes than to the poor.
We do want to see more services locally provided and out of hospital possibly run by GPs. We see significant differences between services provided by profit making firms and not for profit organisations. There might be a role for both. And possibly for worker co-operatives.
The essence of socialism is the way services are delivered. Privatised services are not always worse. Competition may induce changes in behaviour.
More patient choice means more travelling and disruption of local relationships with social services. We need more vigilance inside the NHS on value for money.
We need to minimise the involvement of national level politicians. We want more local democracy and accountability and less central control. This will imply more local variation in services and probably a central core of services which must be provided everywhere. There will always be rationing. The only question is how it is to be done. But the need for healthcare is not infinite, though demand might be.
Present mechanisms for local accountability – patient forums, PCT boards, local scrutiny committees – are weak, lack expertise, resources and muscle. A fig leaf over the indecency of lack of democratic accountability. Accountability should be broadly defined. Not a bad idea to separate services currently directly provided by PCTs into separate organisations.
The idea of an NHS constitution or board merits consideration. It could separate the NHS from the electoral cycle and embody NHS values, if we can agree what they are. Public health should be given back to local government.
Introducing pluralism now could mean the subsequent development of monopolies. Social enterprises may be more resistant to take over than commercial organisations. European law may have an impact on the development of pluralism. A directive is to be expected early in 2007. The plan that 15% of elective surgery in each PCT must be provided by the private sector appears to have been dropped. There is now no minimum or maximum for private work.
What we want to see in the next Labour Health Policy (these are individual ideas, not all discussed):
- Restoration of democracy to local labour parties, power to local authorities and commitment of a Public NHS
- NHS administered by an independent board separated from politics and accountable to Parliament
- Individual contract between citizen and health practitioner about healthy living and mental health
- Independent health service apart from politics like BBC
- Adequate funding for effective treatment of cancer and heart disease – an end to postcode lottery
- Scrap payment by results
- Development of more local democratic control of PCTs
- Care free at the point of entry to the NHS
- Community development as a force in PPI
- Co-operation to replace competition in the NHS
- New socialist view of health
- Withdraw from all contracts with private sector and stop funding discrete projects and give money to front line
- Reduce inequalities with attention to poverty and sufficient income for healthy living
- Joined up thinking across health and other Depts – eg choice of school discourages walking and after school activities
- Greater balance of principles of choice over good provision for all
- Greater honesty over what is possible – realistic expectations.