The progressive marketisation of the NHS has been a cause for continuing concern to the SHA but did not provoke serious debate by Central Council until 2005 when the SHA was invited to affiliate to the newly established Keep Our NHS Public campaign (the aims and objectives of the KONP campaign are below at Appendix 1).
Central Council considered whether or not to affiliate at several meetings and having initially narrowly voted not to do so eventually, again by a small margin, voted to affiliate in April 2006. It was agreed to affiliate for one year only in the first instance and to review the decision at the end of this period in the light of what the KONP had achieved. This review will be carried out at the Central Council meeting in April 2007.
Since the start of our continuing debate about the marketisation of the NHS and what should be done about it two things have changed. Firstly, any lingering doubts about the government’s intentions in respect of marketisation have now disappeared in the face of incontrovertible evidence that it is fully intent on marketising all the public sector including the NHS. Secondly, there was a real concern that the KONP campaign was essentially a negative one which used any pretext to be critical of government action. It is now evident that the leadership of KONP have formed the view which we hold namely that we need to be positive and chart a new direction of travel for the NHS that does not involve marketisation but which is not simply a turning the clock back exercise.
At its last meeting the KONP Steering Committee agreed to set up a working party, which included SHA representation, to look at the options for a new direction of travel. And the SHA Executive has been trying to do something similar with its Fresh Start paper. A version of this (Appendix 2) was considered at the last meeting of Central Council when the following comments and decisions were made:
“It was agreed that the officers should redraft the section on key elements. This should start with positive comments: emphasis on the need for strategic role of commissioning and a level playing field. The five points listed in the Health Composite motion moved by Unison at LP conference should replace the list calling for the discontinuation of PFI, payment by results etc. Eddie Coyle would redraft paragraphs dealing with democratic accountability and commissioning, and John Lipetz would redraft the final paragraph on strategic planning and the executive function. A revised draft would be discussed by officers at their next meeting on 21 November and circulated to Central Council members. It would form the basis of a submission to the Health Policy Commission.”
The Executive, as instructed, has endeavoured to produce a revised draft Fresh Start paper but has formed the view that the issues involved are so major and the government’s resistance to change is likely to be so great that a more considered and a more collaborative approach to defining a new vision for the NHS is the only one which has any chance of success.
A Way Forward
In terms of immediate action Central Council has already agreed that the policy on immediate action agreed by the 2006 Labour Party Conference, detailed below, should be promoted:
1. More time and flexibility be offered to Trusts and PCTs to achieve financial balance, to ensure that cuts are not made which damage local health provision and will incur wider costs later;
2. No further extension of payment by results until a full assessment of the consequences for the local health economy has been carried out;
3. The further outsourcing of services to the private sector, such as NHS Logistics, to be subject to review with full consultation throughout the Party and the NHS to consider the impact on trust budgets and the co-ordinated provision of services;
4. All NHS stakeholders, including patient groups and trade unions, to be fully consulted and included in policy discussions.
5. The Government to ensure that structures for patient and public involvement work effectively and that the public have a genuine say over commissioning and configuration decisions.
For the longer term the focus must be on defining a new direction of travel – or even several new directions of travel – for the NHS in England in active collaboration with other organisations with a similar interest such as UNISON, AMICUS and of course KONP. The work done so far on this in developing the Fresh Start papers should be used as a starting point, particularly the set of principles agreed by Central Council and reproduced below:
” We believe that healthcare must continue to be provided free at the point of delivery solely on the basis of clinically determined need and that it should be organised to meet explicitly defined individual and community needs;
” We believe that it must be accountable to locally elected bodies answerable to the people they serve through elected representatives.
” The reduction in inequalities in access to healthcare must be a prime objective for the NHS, as its contribution to the reduction in overall inequalities in health.
” We believe in the principle that ‘valued staff value people’. This means services should be delivered by staff with terms and conditions in line with the NHS Agenda for Change agreement; and that trade unions should be fully recognised in any unit or organisation providing NHS services.
” Every healthcare encounter in each healthcare setting should take full advantage of the opportunities for lifestyle counselling in pursuit of the prevention of disease and the promotion of health and wellbeing.
” We consider that the public sector and particularly the NHS has, over the last 60 years, developed a culture and way of working, the public sector ethos, comprising among other things, compassion, pride in ones work, selflessness and a feeling of belonging to a worthwhile and much valued organization, which is uncommon in the private sector and which is worth retaining and developing because it adds value to the service delivered to the patient / user.
Very helpfully, our Director has recently outlined some of the factors that he considers should be taken on board by the Labour Party in updating its Health Policy in readiness for the next Election. These are detailed in Appendix 3. These factors, among others, should, we believe, be taken into account in developing a new future for the NHS in England.
Two of these factors are particularly worth highlighting. Firstly, the desirability of looking at what is happening in the NHS in the 3 devolved administrations including particularly Scotland where the purchaser/provider model has been rejected in favour of a directly provided one. Although the contexts are slightly different in the other three countries of the Union there may well be lessons to be learned for the future NHS in England. And secondly, the pressing need to give greater priority to the prevention/public health agenda, particularly the wider determinants of health and the developing holistic concept of Wellbeing. The current focus on the NHS has inevitably tended to relegate public health even further down the agenda.
Recommendation
1. That the SHA continues to develop its thinking on an alternative future for the NHS in England BUT in active collaboration with other organisations such as UNISON, AMICUS and KONP and incorporating the key principles set out above. As far as possible this should be integrated with the Labour Party policy making structure.
2. That the programme of Conferences for 2007/08 be used to inform the development of an alternative vision. In particular, we should look at what might be learned from what is happening to the NHS in Scotland, Wales and Northern Ireland. A rigorous evaluation of what is happening in the other countries is essential so that lessons learned that might be applied in England are evidence based. A framework that might be applied in such an evaluation is detailed in Appendix 4
3. That the Executive report back at each Central Council meeting on progress with the alternative futures work with the expectation that significant progress will be made by the time of the AGM in 2008.
APPENDIX 1
AIMS AND OBJECTIVES OF THE KEEP OUR NHS PUBLIC CAMPAIGN
Aims
- To inform the public and the media what is happening as a result of the government’s ‘reform’ programme.
- To build a broadly based non-party political campaign to prevent further fragmentation and privatisation of the NHS.
- To keep our NHS Public. This means funded from taxation, free at the point of use, and provided as a public service by people employed in the NHS and accountable to the public and Parliament.
- To call for a public debate about the future of the NHS possibly by setting up a genuinely independent Royal Commission and to halt further use of the private sector until this has reported.
Principles
We believe that the most equitable and efficient way of providing health care is by:
- Using the simplest and therefore most cost-effective system of administration of the NHS based on planning and co-operation rather than market forces.
- Removing the purchaser provider split introduced in 1990.
- Re-integrating the service with each area having a single administrative body democratically elected and responsible for providing all primary, secondary, community and ambulance services for its population. This centrally allocated budget should be on a per capita basis with adjustment for deprivation. Minimum care standards of provision should be set based on good public health information.
- Stopping further use of the private sector until proper data about the effect of existing projects have been evaluated by independent researchers. Proper governance procedures and openness about costs (ie removal of commercial confidentiality clauses) is necessary.
- Not embarking on major reconfigurations of services away from the network of District General Hospitals without consultation with the local population and a proper evaluation of both medical and economic benefits and costs, including transport costs to the environment.
KONP STEERING GROUP 6.12.06
APPENDIX 2
The Fresh Start paper presented to Central Council in October
APPENDIX 3
Political perspective on developing Labour Health Policy
We have now run three conferences on this topic (and cancelled a fourth). Attendance was disappointing, whether because nobody cares any more or because they were on Saturdays before Christmas we will never know. There are no randomised controlled trials in politics. These are my own reflections on the current state of play.
1. Health inequality, and public health in general, is still very low profile. The targeted individualised approach which HMG are taking does not upset anyone outside Public Health. The fact that there is little evidence to support some of these initiatives doesn’t seem to be a cause for concern. It is difficult to get politicians worked up about the fact that the life expectancy of the rich is rising more rapidly than that of the poor. The most important, and most difficult, task for the SHA is to raise the profile of the wider determinants of health and income inequality in particular. There is still a great deal of work to be done to raise the profile of health as opposed to illness.
2. There is very widespread agreement that further centrally directed structural change is to be avoided at all costs.
3. Pluralism, privatisation and competition has still got a considerable head of steam in it. Much more from the staff side than the patient side. It is difficult to find a patient who cares much whether they get care or treatment directly from NHS staff or from some agency paid for by the NHS. But it is equally difficult to find a patient who is much impressed by the choices currently being offered. Patients are quite interested in certain sorts of choice, but they are not very keen on going further away from home for treatment and they want a lot more information if they are to be given the opportunity to make decisions. There is a good deal of rubbish produced by both sides of the argument about choice and competition. Those who embrace competition do not seem able to produce much evidence of its supposed beneficial effects in a healthcare setting. There is a lot of talk about payment by results, but inability to comprehend that for many medical problems the only measurable result is eventual death, that many medical conditions are poorly defined and that what we have to pay for generally is that ill defined commodity “care”. Those who denounce privatisation use the term so widely that it loses any precise meaning and attribute all difficulties to it without any attempt to demonstrate causation. KONP conveniently forget some of the effects of the NHS monopoly – in particular the manipulation of the system by surgeons for their own personal profit. The SHA might be able to improve the quality of the debate by challenging both sides. Traditionally privatisation was used when some government run service was transferred to the private sector, usually with its premises and staff. That is not what is happening generally in the NHS, although it did happen in the NHS Logistics case. The word Marketisation is more appropriate for what is generally being introduced because the services being provided by commercial organisations are in the main additional to what was previously provided by the state.
4. KONP make a comparison between ITV and BBC – both free at the point of use – which is worth exploring a bit more widely. If we are arguing that there is a difference between services provided directly by the NHS and those provided under contract we need to provide a coherent explanation of what that is. Although perhaps KONP do not realise that these days quite a lot of BBC programmes are commissioned, not made by their own staff. If we object to the idea of the NHS becoming just a logo, a brand which carries a guarantee of certain quality standards, we need to make a case which will appeal to patients, not just the staff of the NHS. Patients certainly are concerned about quality and safety, and there is a growing lobby of dissatisfied patients which has realised that hospitals are not the safe places they might be. Is there any UK evidence to suggest that private healthcare is less safe or of lower quality? Points suggested which we might make about commercial healthcare providers (NB these do not generally apply to the not for profit sector:-
- a) loss of altruistic ethos
- b) profits/shareholders make services more expensive
- c) if the profits go, the company will go. The system will become very unstable. Takeovers, etc. (though hardly less organisationally stable than the NHS has been for the last 20 years)
- d) gaming becomes the norm – anything will be done to make profits rise
There may be other points we can make, but we need to substantiate these points with evidence that there is really a difference from public sector organisations.
5. The procedures provided by the NHS for dealing with complaints and medical harm have in the past been seriously inadequate. There have been repeated changes and the NHS Redress Act has just been passed. We need to revisit this area. The advent of the NPSA has raised the profile of untoward incidents considerably. The general public has yet to realise that the chance of acquiring further medical problems as a result of admission to hospital is more than 10%.
6. There is no evidence that the NHS is becoming less free at the point of need. No political party is proposing to introduce more charges. There is no point in us campaigning on this point. There has always been a problem with long term care, and I think that the situation now is slightly better than it was. In any case issues about long term care are nothing to do with marketisation. There are however some increased costs associated with choice – principally travel costs for patients, and these merit some investigation. There are also considerable worries about whether the principle of universalism will continue to be defensible. There are clearly a great many new and expensive treatments becoming available and there will at some point be discussion about whether it is acceptable to permit people who have the means to pay for services which are not provided free by the NHS.
7. Local accountability has always been very weak, and we should be demanding new and better mechanisms, not pretending things were better in the past. Individualised choice – if it ever happens in a significant way – is not a substitute for community voice because there is never going to be much choice about the handling of urgent or long term care. We need to continue to develop policies in this around local accountability especially in relation to commissioning. We should try and persuade our members to help make the LINKs idea work – and at the same time look to see how things are done in Wales and Scotland. This might be the key to many problems. If local decision making is genuinely accountable and robust it seems unlikely that there will be widespread introduction of profit making providers, but if a local population can really be convinced that a profit making provider will give them a better service than an NHS provider then it is hard to see why we should object. Equally I think the only way the NHS will ever be able to close hospitals and survive politically is by setting up some system whereby the local community can be convinced that this is the right thing to do.
1. We can talk about accountability at an individual level – the individual patient and their relationship with those who treat them. Full medical record access for all could promote shared decision-making and decision aids for patients could support them making the decisions that they feel they want to
2. At a Practice level: Local committees running the practices, with the partners. This would link closely with PBC, if that continues.
3. In a locality community development is a key approach that will link local people, patients, disease groups and accountability in an organic whole that leads to both better health and better PPI. Extend Foundation Trusts to PCTs but ensure better arrangements?
8. There has been a lot of concern about marketisation “fragmenting” the NHS, and about maintaining its “structural integrity”. I am not sure what people mean by this. As a patient I have always experienced the service as fragmented. When I go to a different part of the NHS they usually know nothing about me and do not accept any conclusions reached about me or my care by a different institution. Perhaps people who live all their life in one village and only ever attend one hospital experience the system differently, but the NHS needs to cope with a more mobile population. If this fragmentation point is important then it needs to be articulated more clearly. One obvious way of connecting up the different parts of the system is Connecting For Health. We should be supporting this and pointing out to all the paranoid opposition that the stuff that worries them about all and sundry having access to their medical records and those records being full of inaccuracies which they cannot correct is exactly what goes on now with paper records.
9. There is clearly mileage in comparing the situation across the internal borders of the UK. For one thing it provides a defence against the charge that the Blair Government are conspiring to demolish the NHS. If that were so why would it be left in place outside England? There are however important differences which might make it difficult to apply lessons across borders. The most important is that there is no private healthcare industry worth mentioning outside England and so little incentive for consultants to manipulate waiting lists. It may also take time before significant differences can be demonstrated.
10. The purpose of the Labour Party’s consultation is to produce a policy for 2009. It is difficult to get people to think so far ahead. Much attention has been given to unpleasant deficit reduction exercises which clearly do not constitute long term policies. Unpleasant though it may be to watch a variety of long term investments which we value sacrificed on the altar of immediate financial balance we need to try to avoid getting sucked into short term debates where we have little influence. We must not be sucked into managerial debates about how things are run. We do not have sufficient expertise to contribute anything useful. In particular the question of whether one way of doing things costs more than another is, in health, almost entirely a question of how various sorts of overheads are allocated. It is not a matter of principle. We do not have to defend the principle of value for money, but we may need to point out how little discussion there is about cheap and effective measures as compared to the endless discussion of the importance of expensive medication which is often not very effective.
Martin Rathfelder Jan 2006
With thanks to Dr Brian Fisher for his helpful comments
APPENDIX 4
Factors to be taken into account in evaluating future options for the NHS in England
- Integration/Coterminosity
- Level of political control
- Worker involvement
- Patient involvement
- Public involvement
- Competition vs Planning
- Commissioning vs Direct Management
- Professional hegemony.
- Private sector involvement
- Opportunities for local variations in organisation
- Capital funding – public versus private
- Balance between district and community hospitals
- Public health and the LA role
- Focus on inequalities