I have been a GP for the past 30 years and survived numerous meaningless structural changes in the National Health Service. But now the coalition is proposing perhaps the biggest change of all: a politically-motivated reorganisation of the NHS to be “developed” in less than 50 days.
The proposed NHS shake-up lacks consultation, piloting and evidence. Health Secretary Andrew Lansley (pictured) is set on the wrong path, pursuing the age-old “solution” to all ills in the NHS: radical restructuring. This contradicts his pre-election promise that the NHS would not be subject to reorganisation.
In theory, the Government’s white paper is championing three issues: patients at the centre of the NHS; changing the emphasis from targets to clinical outcomes; and empowering health professionals, in particular GPs. In practice, this would create only illusive empowerment for GPs and patients. It’s a recipe for confusion, inefficiency and demoralisation. Apart from foundation trusts, very little of the existing architecture will be left unchanged. Lansley’s health white paper opens the door to the comprehensive privatisation of healthcare. The proposals on GP commissioning are a smokescreen for implementing the old, failed Tory policy of voluntary fund holding – and on a larger scale. At the last Labour reorganisation in 2006, 303 primary care trusts were reduced to 152. Such is the lack of precision in the current plans that it is not clear where the coalition will get 100 consortia from, let alone bridge the gap of the estimated 500 and 600.
Doctors have it drilled in them that they must practice evidential medicine, so it is understandable that the lack of any evidence base for this controversial strategy is causing concern. What manner of game is this, where the stakes are so high and the odds for success reduced to the throw of the dice?
Implementing Lansley’s changes in the absence of any proof that GP commissioning would be superior to current arrangements would constitute a victory of dogma over evidence. Commissioning means purchasing, fundamental to a market system. The notion that GPs will have major control over the commissioning process doesn’t stack up.
The white paper demands a market-based approach that must involve competition between a plurality of “any willing providers”. The idea that GP consortia would be able to favour their local provider and build excellent local services is fanciful. The consortia of GPs established to spend £80 billion in commissioning budgets will become little more than rationing committees, choosing which services should be cut and which sections of patients should lose out.
Many GPs are unconvinced by Lansley’s plans. GPs are neither trained nor experienced in managing whole-health economies, nor do many have more than a passing understanding of the impact of decisions on large institutions such as hospitals.
This is not why they went to medical school. If they had an interest in helping the Government to run the health service, they would have studied economics.
So lack of expertise is one obvious problem. GPs will have to look elsewhere for assistance, driving them into the clutches of big private providers. One consequence may be to accelerate the movement towards polyclinics and specialist units, as advocated by Lord Darzi for the last Labour Government.
What also worries doctors and patients is whether there will there be enough money. If a consortium spends more than its fair share, who foots the bill? If the practice runs into financial difficulty, not only will they carry a personal risk but many patients will lose out.
There is likely to be intolerable pressure on clinicians to dilute their needs-led approach to patient care and instead consider all manner of economic and other factors. Patients are right to be worried, because GP practices are not set up to do this. They are clinical enterprises, not businesses. Nor are they sophisticated Government bodies with the appropriate range of skills and expertise to use taxpayers’ money sensibly to get the best for less.
Burdening GPs with commissioning against their will is unfair, will not work and is likely to create a degree of chaos in the system that will be costly to remedy and not necessarily be in the best interests of patients. Further, Nuffield Trust research suggests that GP commissioning may add £1.2 billion to NHS expenditure. Any dysfunction could threaten secondary and tertiary care. In these unchartered waters, no one wins.
A report by the Civitas think tank has said there is little evidence GPs will be better off than they are under current system and warned that the restructuring could set the NHS back by up to three years. The fear is that the coalition’s experiment would be more costly than current arrangements, widen health inequalities and reduce patient satisfaction.
Further, by 2014 every hospital should be a foundation trust and allowed to leave public ownership while still providing public services – taking the cash with them. They would be like universities – able to sack staff and close departments pretty much as they please. Employees might be forced to abandon the NHS pension scheme in favour of a pension or share option offered by foundation trusts. The trusts would be allowed to introduce variable pay schemes across the NHS.
Lansley has also decided to remove the cap on foundation hospitals’ private work, allowing them to lure wealthier patients for specialised surgery, thus strengthening the grip of markets in the health economy.
But this isn’t just about the Conservatives and the Liberal Democrats. The last Labour Government laid the groundwork for everything the coalition is planning to do to the NHS. The market structures, foundation trusts, as well as the insertion of American corporations into commissioning and GP consortia were all products of the Tony Blair and Gordon Brown version of “public service reform”.
At the heart of Lansley’s agenda may be the complete privatisation of the NHS – a process that has deep roots in Thatcherite ideology. We may be witnessing the end of the NHS as a publicly provided, publicly-financed body. We are inexorably moving away from the traditional health service to one ruled by bogus choice, competition, market forces and diversity of suppliers.
Lansley believes that public money should be used to bring in more private providers and create competition. However, using public money to help the private sector and introducing market forces into healthcare are anathema to everything the NHS stands for.
The white paper is the biggest challenge to core NHS values. The coalition is planning to turn the NHS over to a plethora of private companies who either commission or provide services, or both.
Opposition to stimulating private-sector competition with the NHS at taxpayers’ expense is not just based on ideology. We should question the very idea that markets in healthcare are the route to improvement. There is now a price on every patient’s head. GP consortia alongside private companies would be able to cherry-pick patients who can be treated simply and quickly, while disregarding those who have complex and chronic illnesses.
The vision outlined in the white paper is one in which corporate interests will be driven by incentives to select patients, time-limit care, sell top-up insurance and introduce charges for some elements of care no longer provided by the NHS. The truth is that universal healthcare provided by the NHS – once the envy of the world – is in serious danger of becoming unsustainable.
The white paper is the NHS equivalent of the poll tax. What we need now is a bold, active and high-profile campaign from the Labour Party, trade unions, the British Medical Association and everyone who cares about the NHS to push this issue to the top of the political agenda and give hope to all those who fear the side-effects of Lansley’s deadly prescription.
Kailash Chand is chairman of Tameside and Glossop primary care trust
