Many say that if the government’s health and social care bill were passed in its present form it would mean the end of the NHS as we know it. Does that overstate the threat?
Colin Leys I don’t think it overstates the threat at all. The bill removes the secretary of state’s responsibility to provide a national health service and doesn’t assign it to anyone else. She or he would only be charged with “promoting” it.
The real power to provide it would rest with GP consortia, which would be answerable only to a national Commissioning Board appointed by the secretary of state.
Patients would get what their local commissioning consortium decided to pay for. There would no longer be a universal service.
All NHS and private healthcare providers would be overseen by Monitor, an independent regulator answerable to no one, on exactly the same basis as other market regulators.
Monitor would have a mandate to encourage competition from “any willing provider”.
What services patients would get would be up to the consortia to decide. They would be under pressure to give the work to the cheapest providers.
They would also have power to eliminate some treatments from the NHS altogether and to set charges for others. What is available would vary from one consortium to another.
Some consortia are already shaping up as weaker than others.
The result would be a trend towards those who could afford it opting for private care, and towards charges for “top-ups” for some things that are now standard NHS treatments. This would mean a three-tier system: basic, basic plus top-ups, and fully private.
This is a logical consequence of the Private Finance Initiative (PFI) and the internal market.
PFI and the purchaser-provider split were precursors—along with foundation trusts, payment by results, personal budgets and the rest—to what Lansley’s bill proposes.
A succession of New Labour secretaries of state pursued this course—as far as possible out of public view because they knew how unpopular it would be if it was fully understood.
How this was done, and what the implications are now, is the story Stewart Player and I tell in our new book, The Plot Against the NHS.
With every advance of private provision—whether of PFI hospitals or private treatment centres—the power of the private sector grew.
As soon as a Conservative government replaced Labour it was likely to take the further step of going for a more or less full‑scale free market.
What was not predictable was how incompetently Andrew Lansley would set about doing this.
Had he proceeded as Margaret Thatcher did with her trade union legislation, for example, in a series of bills, taking one aspect at a time, he could have got away with it.
But seeking to do it all at once, without preparing even his colleagues, and without thinking through half the critical issues that it would raise, has finally put the Lib Dem rank and file on a collision course with their leadership.
This has created a crisis for Nick Clegg, and so for the coalition.
Given the political unpopularity of the “reforms” why are the Tories doing it?
I think it is Lansley and his private sector backers, rather than the Tories as a party, who are doing it.
My impression is that most MPs of all parties, including David Cameron, had, at least initially, a limited grasp of the implications of the bill.
This is not surprising when you consider that health policy is very complicated, not sexy, and the moves to the market have been as far as possible undertaken stealthily.
So instead of trying to educate the public about health policy over the last ten years, every effort was made to minimise the significance of each step, so that the overall picture remained poorly understood.
Among the Tory party there is support for the private sector and, in general, a lack of personal concern with the NHS. Lansley took advantage of this to promote a bill that was full of danger to the Conservatives.
He may also have misjudged the public attitude to privatisation.
Because the steps taken by New Labour since 2000 were done on the back of unprecedented increases in NHS funding, services improved while privatisation advanced.
But the combination of cuts in NHS provision with the revelation of what a full healthcare market actually means has changed this.
Why are cuts being made after we were told that the NHS budget was being protected, and how do they relate to Lansley’s bill?
The NHS budget is actually being cut by about 1 percent a year in real terms. But much bigger spending cuts—between 4 percent and 7 percent a year—are now being made across the board.
Some of these cuts relate to what is planned in Lansley’s bill.
Primary Care Trusts have been told to wipe out any accumulated deficits so that the new GP consortia can take over the work of commissioning with no debts to pay. Something similar is happening in hospital trusts.
Those with big accumulated deficits, and not least those with big annual PFI payments to make, are making the needed economies in the only way they can: by cutting staff, since staff account for most of their costs—and that means cutting services.
But on top of these bill-related cuts are so-called “efficiency savings” that are also being imposed across the NHS.
The justification for these is that while the NHS budget remains fixed, the cost of drugs, electricity, equipment, and so on, is expected to rise, and the healthcare needs of an ageing population are expected to grow.
Neither kind of cut—those to do with the bill, nor those stemming from chancellor George Osborne’s freeze of the NHS budget—has ever been clearly explained to the public. To do so would raise questions about the cost of the market-based system itself, which probably accounts for about 10 percent of the total NHS budget.
Getting rid of the market, as the Scots and the Welsh have done, would make a major saving.
Explaining the cuts would also raise questions about where the so-called efficiency savings will go if and when they are achieved.
Will they go to pay private providers to take work away from NHS hospitals? And how will cutting staff make it easier for the NHS to provide more care for an ageing population?
How seriously should we take Tory promises to “pause” and listen? How much can the Lib Dems change the bill?
It’s not clear how far the pause was imposed by Cameron. My guess is it was, and Lansley’s initial interpretation of it was that it would give time for us to listen to him, not the other way round.
When it was clear that that wouldn’t fly, Cameron, Clegg and Lansley jointly announced the formation of a “listening forum” of some 40 people.
But the listening forum has been comprehensively packed with pro-market people, without a single reputable critic of the bill among them. And the views it is now proposed to listen to are limited to those of people in the community health and voluntary care sectors.
Its job will be to produce recommendations for amendments to the bill that do not affect its main aims.
The only amendments so far on the table that do go to the heart of the bill are those developed by the Social Liberal Forum, under the leadership of Dr Evan Harris.
These spell out the implications of the critical motion passed at the Lib Dems’ Sheffield conference in March.
Taken together, those amendments would eliminate most of the bill’s measures that matter.
Now that Nick Clegg faces a potentially terminal loss of rank and file support, following the defeat of AV, council losses and the wipe-out in Scotland, he can’t avoid seeming to take a strong stand against Lansley’s bill and argue for major changes.
But unless he adopts the amendments wanted by the rank and file, they won’t be major and the rank and file will know this.
On the other hand, if he goes as far as the rank and file want, Lansley can hardly continue as secretary of state.
The task for everyone who wants to defend the NHS is not to relax but to increase the pressure. Above all we need to prevent the media from colluding in a lazy muddling of the issue.
The US healthcare model is often cited by those on the right of Tory party as their inspiration, but how efficient is it for capitalism as a whole?
The ruling class likes the fact that that the US system provides high quality care for the most highly insured minority such as themselves, and the scope it offers for the private healthcare and insurance sectors to make money.
They will be content to have a residual or “basic” system of healthcare for all paid for out of taxation in England, provided that the tax bill for it is reduced through the addition of other payments and private healthcare remains available for themselves.
Almost every professional body and union in the NHS opposes the government’s “reforms”. How significant is that?
All recent British governments have shown a readiness to ride roughshod over mass opposition, whether over Iraq or student fees.
The one lever we all have is to make it clear we will never again vote for any party or any individual politician who is complicit in the destruction of the NHS.
We need to make this clear to every individual MP and councillor—and every GP and every hospital doctor, and every PCT board member—in every possible way.
We need meetings, letters, phone calls, visits to their offices, as well as demos and marches—as long as it takes, until the bill is dropped. It’s a job for every single one of us.