The government is in serious trouble over its plans for the National Health Service. Gill George explains exactly how the bill is intended to destroy the NHS as we know it
Just before the general election David Cameron promised that there would be “no more top-down reorganisation of the NHS”. This was a straight lie. The Tories’ attempt to dismantle the NHS has been a long time in the planning.
Back in 2005 Andrew Lansley made a speech to the NHS Confederation spelling out Conservative priorities for the NHS. These included privatisation, a pro-competition regulator and the delegation of NHS budgets to GPs. The building blocks of the Health and Social Care Bill were there from the very first days of Cameron’s leadership of the Tory party.
What has changed since 2005 is the imposition of £20 billion in cuts to the NHS. There is no slack left in the system at all. The standard of patient care is now plummeting. To divert around £4 billion away from patient care and into restructuring and to spend £1 billion just on making health workers redundant – this is to display a shocking contempt for the NHS and the people it serves.
The Health and Social Care Bill as a whole is a shambolic and incomprehensible mess, with the confusion heightened by the plethora of amendments thrown at it in a desperate attempt by the Tories to keep the Lib Dems on board. There is much here that is rotten. There is one theme, though, that runs through the bill like the letters through a stick of rock: privatisation. This ideological agenda is the driving force behind the legislation. The intention here, behind all the spin, is the straight transfer of billions of pounds of public money to big business, and with an English NHS budget of over £100 billion, the potential profits for big business are enormous.
The provision of healthcare is to be opened up to “any qualified provider”. This is code for squeezing out NHS workers and bringing in private sector providers. The reference to “qualified” here is a formality. Would-be providers of NHS services will be clinically approved by the discredited Care Quality Commission (CQC) – a “light touch” regulator slammed by the National Audit Office last year for its box-ticking approach to ensuring the quality of health and social care.
The CQC relies on organisations assessing themselves and reporting any problems – an explanation, perhaps, for the CQC’s failure last year to spot the disgraceful abuse of people with learning difficulties at the Winterbourne View care home. As more and more resources are diverted into rubber-stamping new service provider applications, such failures will get worse.
The concept of NHS-run hospitals will effectively end under the proposed legislation. All NHS Trusts in England will be required to become “Foundation Trusts” – stand-alone small businesses that have a future only if they compete for work successfully and remain financially solvent. Phase two is likely to be a requirement that current NHS Trusts become “social enterprises”, strengthening the notion that there will be no public provision and no public accountability of healthcare in the future.
It is unlikely that existing NHS providers will survive in the long term, nor are small voluntary sector organisations and social enterprise companies likely to have much of a future in the healthcare market. It is noteworthy that Assura – a company majority owned by Richard Branson’s Virgin Group – won a £490 million contract to provide NHS community services last autumn against competition from social enterprise Central Surrey Health and two local NHS Foundation Trusts. At a simple level, it’s a corner shop versus Tesco scenario. Over time big providers – with the potential for economies of scale, slick marketing and loss leader bids – will simply squeeze out small organisations seeking to provide healthcare.
The government went into a bit of a flap after the failure of Southern Cross care homes last July, realising that many private providers of healthcare are heavily in debt and at risk of bankruptcy if they are unable to maintain payments on their loans. And when NHS or private providers go broke, or private companies walk away from an unprofitable contract, patients pay the price, the media don’t like it, and the Tories risk a bad press. There are currently no meaningful provisions in place to deal with provider organisations that go bust or give up.
This is not a theoretical risk. The priority for private sector companies is simple: profit. The consequences can be seen very clearly in Camden just now. In 2008 UnitedHealth won the contract to provide GP services to three practices (despite overwhelming public opposition and strong counter-bids from local GPs). UnitedHealth then decided there was more money to be made out of “commissioning support” and decided to give up any ongoing role in primary care. Ownership of UnitedHealth Primary Care – a subsidiary of UnitedHealth UK – therefore passed to another private sector company, The Practice plc.
The Practice, facing allegations of inadequate service provision and the employment of a single GP where three were required, simply announced in February that it will close the busy Camden Road practice in April. Around 4,700 patients face the loss of a local GP service that has existed since the inception of the NHS.
The fact is that competition and the profit motive cannot be made to sit comfortably alongside an NHS that is about patient care. Historically, the NHS has always depended on risk pooling. It’s irrelevant that one area has a flu epidemic and another doesn’t; that one area has a higher proportion of patients with complex needs than another. In a nationally run and nationally funded health service resources can simply be directed to where they are needed. Labour in office began to destroy that notion. The Tories now intend to reduce the NHS to nothing more than a loosely regulated market system – akin to the provision of electricity or mobile phone services.
UnitedHealth’s decision to focus on “commissioning support” may be a clever one. The Tories pretend that the NHS “reforms” are about empowering frontline clinicians and improving patient care by giving budgets and control to GPs. This is spin, of course. GPs are being grouped into new organisations called “Clinical Commissioning Groups” (CCGs). These are not about local control and designing services that meet local need. There is growing policy and financial pressure for CCGs to merge into vast organisations, set to cover patient populations of perhaps a million people. The idea that an individual GP can exert meaningful control over such bodies, presumably in a tea break in between seeing patients, is clearly nonsensical.
So who will really run the CCGs if it’s not the GPs? That’s where UnitedHealth comes in – alongside McKinsey, KPMG, Capita, Deloitte and all the others. This is where the really rich pickings are to be had. GPs nominally have control of 80 percent of the NHS budget: say around £80 billion. They don’t have the time, know-how or inclination to run large businesses. So what they need, apparently, is “commissioning support”. The idea is that the new GP consortia will employ private sector companies who will spend the money for them. The plan is that four fifths of the English NHS budget is to be given to the private sector to spend as they see fit. This is not “creeping privatisation”. This is out-and-out robbery. The audacity of the proposals is genuinely shocking.
The complexity of the plans makes it hard to spot what’s happening. Currently clusters of Primary Care Trusts – the old NHS organisations that are being done away with – have the job of setting up new bodies called Commissioning Support Services (CSSs). In many cases these are being set up under private sector guidance. McKinsey is “advising” in London; Capita in Cheshire, Warrington and Wirral; KPMG in Hampshire and so on. The plan is that these CSSs will become stand-alone businesses between 2013 and 2016.
There will be only 25 to 35 of these commissioning support organisations to cover the entire country. In theory, local authorities or small voluntary agencies could take on these CSS enterprises. But what local authority or charity has the resources to plan and purchase healthcare for a million and a half people, perhaps providing IT support, payroll services and such like as well? The proposals are designed to exclude all but the biggest private sector companies. Big business will control the budget and will decide which services the NHS will offer. Big business will buy those services – and, most likely, will buy them from their private sector pals. Within a very short space of time the NHS will be unrecognisable.
Ducking the blame
There are plenty of other problems with the Health and Social Care Bill. It ends the responsibility of the Secretary of State for Health to ensure the provision of comprehensive healthcare (care that covers all conditions). This is about cuts and privatisation and ducking the blame. Although NHS care will continue to be free at the point of delivery, this means very little when CCGs can simply decide that essential treatments will no longer be provided by the NHS.
This is already happening in some areas, with restrictions placed even on mainstream procedures such as hip or knee replacements, and people excluded from treatment not on valid clinical grounds, but because they smoke or are overweight. Currently this happens because of the £20 billion in cuts. In the future an additional motivation for cutting NHS services will be to flog private care to patients. The removal of the secretary of state’s responsibility is a trick – we’re meant to blame GPs, not the Tories, as the NHS disintegrates.
Lansley claims that competition will be about quality, not cost, so care will just get better and better. The dishonesty here is breathtaking. Proposed restrictions to cost-based competition will apply only to hospital services covered by the “national tariff” – the services that already have a fixed price. Mental health services, all community services and 40 percent of hospital services are excluded from this (minimal) protection. Competition for these services in a cash-strapped NHS will inevitably be on the basis of cost. The future for patients with mental health difficulties is bleak. And community services (health visiting, district nursing and so on) are at the core of the NHS; these are the unglamorous services that keep children safe and allow older people to live with dignity. These services are set to be smashed to pieces.
Foundation hospitals will be allowed in the future to make 49 percent of their income from private patients. This is a huge shift, paving the way for a private insurance model. The £20 billion in cuts is already having a devastating impact on patient care. The new CCGs or their CSSs can simply rule that particular treatments are no longer available on the NHS. Hospitals will be touting for private business as the only route to financial survival. Patients will learn quickly that if you want adequate healthcare, you pay for it, either upfront or through private health insurance. If you can’t pay, you don’t get treated. USA, here we come.
The bill also brings the provision of healthcare under competition law. Private companies that feel hard done by will be able to complain to a body called the Competition Commission and will also have recourse to EU competition law. And, importantly, there will be no requirement for the companies that provide NHS services to abide by NHS national terms and conditions of employment. Workers, as well as patients, will be brutally squeezed. After all, those profits have got to come from somewhere.
This is a key moment for NHS campaigners. The Lib Dems are nervously counting their wafer-thin majorities, and the Tories are panicking. Cameron’s insightful comment on the Health and Social Care Bill – from a Tory perspective, of course – is, “We’re f***ed.” At Cameron’s NHS summit in February there were only 14 people round the table, including Cameron and Lansley, because any organisation known to be critical of the bill had been excluded in advance. The Department of Health refused to identify attendees, presumably so as not to ruin their reputations, but many of those who went to the meeting have now come forward to report that they attacked the bill.
The Tories’ NHS crisis has come about because of opposition from below. Keep Our NHS Public has campaigned against this legislation from the start, as have the Unite and Unison unions. Health campaigners like John Lister and Allyson Pollock have worked heroically to expose the Tories’ agenda. It’s often felt like an uphill struggle though. MPs and journalists have remained until recently in cheerful ignorance.
In the last few months things have changed. Hatred of the Tories has grown, with their attacks on higher education, benefits and the welfare state, and public sector pensions. Organised opposition to these attacks began to crystallise in the magnificent industrial action of 30 November. This has fed into the opposition to NHS privatisation.
A crucial factor though, particularly in grabbing public attention, has been the condemnation of the bill by organisations representing NHS professionals. The British Medical Association (BMA) and the Royal College of General Practitioners have been central to this. The attitude of both organisations was initially ambivalent. A minority of unprincipled GPs have always seen the bill in terms of personal gain through their own private sector links. A far larger number genuinely believed that access to the NHS budget would give them more control and influence. They had illusions that they could improve the NHS, and were slow to understand the real Tory agenda.
But as “efficiency savings” have begun to cause deep harm to the health service, most GPs have understood that they risk being the scapegoat for Tory cuts. They are seeing the slide towards chaos as Primary Care Trusts are abolished and tens of thousands of skilled NHS staff are sacked. They have begun to understand the market agenda that lies behind CCGs and CSSs. Doctors are also angered by the attacks on their pensions. If the government wants to fleece you, make you work until you’re 68 and then give you a pension worth significantly less, why trust them on NHS reform?
We now have the total opposition of the BMA, the Royal College of General Practitioners, the NHS Consultants’ Association, the Royal College of Paediatrics and Child Health, the Royal College of Nurses, the Royal College of Midwives and the Chartered Society of Physiotherapists among others.
These are not naturally militant bodies. They oppose the bill because their members understand this is about the destruction of the NHS. Lansley can no longer claim to have the support of health professionals because as health workers we now stand united in our opposition. Cameron can no longer even visit hospitals safely, if recent reports are to be believed. The breadth of opposition to this legislation is now extraordinary. When NHS campaigner June Hautot ambushed Lansley outside Number 10 and told him, “We’ve had enough of you,” she spoke for millions of people.
The opposition is late in the day, but important. If the bill goes forward, the Tories will take the blame for every cut and closure and every failure of the NHS. If they retreat, it is a massive defeat that leaves our side stronger and more confident.
Whatever the outcome, Lansley is damaged goods and unlikely to survive; whatever the outcome, Cameron has magnificently achieved the “re-toxification” of the Conservative brand. On our side, the anger over the Health and Social Care Bill can feed into a host of other battles. This is a government that’s in trouble.
Gill George is a health worker and a member of the Unite union
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