NHS SOS

Richard Murgatroyd of Huddersfield Left Unity reviews ‘NHS SOS’ and offers a personal view on what privatisation of the health service could mean for the Left Unity project.

Last week the Royal London Hospital was forced to turn away emergency patients for two days running due to a shortage of beds. The boss of the local NHS Trust in a masterful piece of management-babble classed the situation as a ‘significant internal event’. There is a natural spike in demand for healthcare in winter, and fears are growing across the NHS that will struggle to deliver adequate services in coming months.

A recently published book of essays called NHS SOS (edited by Jacky Davis and Raymond Tallis) clearly explains the significance and implications of the current crisis facing the health service. This goes far beyond the drastic £20 billion of ‘efficiency savings’ the NHS is supposed to find over the next few years. For as the veteran campaigner John Lister puts it, the NHS was effectively ‘abolished in April 2013’, when Andrew Lansley’s Health and Social Care Act 2012 finally passed through Parliament.

The contributors in this book pull no punches and any thinking person will be left in no doubt that the changes have massive implications. They also clearly expose how an unholy alliance of vested interests and free-market fundamentalists have betrayed the NHS. The main culprits in this sorry tale are: the politicians – especially Labour politicians, a surprising number of whom have financial relationships with private health care companies ; the royal colleges and professional associations representing doctors and practitioners; and the media who have consistently failed to inform people about the true implications of the changes. According to the authors all this is ‘a symptom of the deep corruption in British politics… the subversion of the democratic process and the collusion of many who should have opposed it’.

What have they done?

The NHS was conceived in 1948 as a cost- effective, efficient and popular provider of publicly funded universal health-care, publicly delivered and publicly accountable. It swept away the mixture of private-for-profit, voluntary and charitable providers that had so obviously failed to meet people’s healthcare needs before WW2. Even 65 turbulent years later it is clear that these fundamental principles remain overwhelmingly popular, despite the many threats and challenges to the service launched by politicians of all parties. Since the Thatcher years these include the creeping privatisation of key parts of the service, PFI, the introduction of a whole series of top-down market-style internal management ‘reforms’ that have fragmented the NHS and encouraged staff to adopt a corporate rather than public service ethos and so on.

At the same time we have seen a campaign from the government and corporate media to flag up the NHS’s inevitable shortcomings and the failures of particular hospitals and services. The underlying message is that the NHS is inefficient, unaffordable and in need of root and branch reform. Don’t mention that in comparison with their privately delivered alternatives even the current model of the NHS offers a better value for money and quality of service!

Behind the scenes, urging on the process, stand powerful financial and business interests, such as SERCO and Virgin, ever-more desperate to find profitable places to invest their capital. While all this is in part driven by an ideological belief in the magical benefits of free markets, as Raymond Tallis puts it: ‘greed was the spur’.

This three decade long period of ‘permanent revolution’ laid the ground for Lansley’s Act which creates a landscape in which private companies can take control of the health care market. The devil is in the detail and you need to read NHS SOS to get a true picture of the enormity of the changes. But in summary:

• The Act abolishes the 12 strategic health authorities (SHAs) at regional level and the 152 primary care trusts (PCTs) that currently commission health care – organising and buying in care for patients from hospitals and other healthcare providers
• Now the majority of commissioning will be done by local clinical commissioning groups (CCGs), which will be made up largely of GPs, with some limited involvement for hospital consultants and nurses.
• CCGs will be expected to promote competition within the service and are forbidden from regarding existing NHS services as the preferred provider. Instead, any qualified provider (AQP), that may include private or charity/voluntary sector organisations, will bid for the chance to deliver particular types of care.
• The CCGs will be overseen by a new national body called the NHS Commissioning Board (NHS CB) – controlling a vast budget and set fair to be the mother of all QUANGOs. So politicians have tried to shunt responsibility for the NHS away from themselves and towards a supposedly ‘ independent’ body, at arm’s length from the government. The NHS CB will also commission primary care services and some specialist services itself.
• NHS trusts will cease to exist in 2014. All hospitals (and other providers such as ambulance and mental health trusts) will have to become foundation trusts (FTs). This moment of transition is a great opportunity for private businesses to take over the management of the new Foundation Trusts, especially if they are experiencing financial problems due to PFI. Foundation trusts will be able to make more money from private patients than currently allowed, potentially as much as 49.99% of their income.

• A new regulator called Monitor will oversee the foundation trusts with new powers to “prevent anti-competitive behaviour” . Monitor will license all providers of NHS services and eventually adult social care providers. Monitor (along with the NHS CB) will regulate pricing instead of the government as at present.
• The major changes in the Health and Social Care Act cover England only, and much of the NHS in Scotland, Wales and Northern Ireland will avoid the level of privatisation in England – for now!

Why does this matter so much?

Politicians of all the main parties have justified privatisation by saying that it doesn’t matter who provides health care. A benign mixture of patient choice, healthy competition and the professionalism of doctors will create a responsive, cost efficient service. Health care will still be high quality and free at the point of use. Who could be against choice?

But as the chapter by Allyson Pollock and David Price clearly shows this just isn’t going to happen. Just a few of the bad consequences of the Act that staff and patients can expect include:

• Most doctors want to be doctors and don’t have desire or expertise to be managers. So inevitably CCGs will outsource their commissioning work to private management consultants and businesses. These will think and act like organisations that exist to make a profit, making key decisions according commercial criteria rather than the public good.
• Key point here is that CCGs will have the discretion to decide which services will be free and which they will charge for. As budgets tighten, the pressure to introduce more charging will increase. Instead of ‘choice’ patients will find themselves facing a post-code lottery and the danger of increased costs
• Staff too will face relentless threats to their wages and conditions. Private companies and voluntary sector providers will need to apply ongoing pressure to cut costs and wages, employ less staff etc to break even and maximise profits. We have already seen how privatisation of hospital cleaning services led to a poorer service… expect more of the same
• Private Health Care companies will cherry pick the ‘easy’ profitable services, leaving public providers to run the more expensive, difficult long-term treatments. This is a funny sort of competition where all the advantages are to the private sector
• As the private sector consume an ever greater slice of the massive NHS budget the struggle for scarce resources between different parts of the service will increase. Fragmentation and a lack of cooperation will increase damaging patient care and undermining the idea of a universal service
• A fundamental shift in the ethos of the service is inevitable. Some doctors and managers will become millionaires and view health care as just another ‘market’ to exploit for private gain. Meanwhile on the ground staff will be forced to give their primary loyalty not to the patient or the wider service, but to their direct employer. Yet more fragmentation and cynicism will result
• Under this system it will be very hard to know who is ultimately responsible – deliberately so. Accountability will blur. So while the NHS brand will continue, the badge on the uniforms will hide the true reality of the service.

The direction travel is now clear and as the ill effects of Lansley’s Act become ever more obvious in coming years we can confidently expect the NHS to grow in importance as a red hot political issue.

Left Unity and a renewed NHS

That Left Unity (or whatever we end up being called) will oppose the privatisation of the NHS is a no brainer. Indeed, since the Labour Party is so thoroughly compromised on the issue we are well-placed to articulate that opposition and form alliances with the many national and local campaigns that will develop in coming years. The fact that Scotland, Wales and Northern Ireland are exempt from the worst effects of the Act shows that the provisions for England are not inevitable and can be over-turned.

Yet while this seems simple enough in principle the changes introduced by Lansley are mind-bogglingly complicated in practice. We’d all need to eat alphabet spaghetti for a week just to learn the list of abbreviations of the names of commissioning and service providers created by the Act. So a key challenge in the short term is to find a way to explain these changes so that public anger is directed at the those really responsible. As importantly, if we are to be a party that doesn’t simply oppose everything we also need to develop positive and inspiring alternatives.

For by the time we are in a position to gain a mandate to govern at the ballot box we should be under no doubt that the NHS, as we have known it, will no longer exist. This is a bad thing, but it also offers opportunities for a broadly based party of the radical Left to restate the guiding principles that inspired the NHS and say how we would make it better than ever. To call for a ‘new NHS’.

Here are a few ideas that could underpin a radical renewal of the NHS:

• Build into the new NHS a holistic approach to health care from the start, so that social and health care services are interlinked
• Take the big pharmaceutical companies into public ownership so that medicines and research are directed to public good instead of private profit
• Regulate the food and drink industry much more heavily to promote healthier food and lifestyles
• Open up the NHS to much more transparency and democratic control

I’m sure we all have ideas on this and the debate should not be confined to experts and professionals. Our Policy Commission on Health, open to all LU supporters, is currently grappling with this (hope everyone is going to the Policy Workshop Conference in Manchester 28th September to join the debate!). No doubt we face years of work to develop our ideas properly.

But in the meantime the kind of ‘significant internal events’ we saw in the Royal London hospital last week will multiply. Now is the time to think creatively about how we can play a positive part in the fight to renew the NHS and this book will help us do it.

NHS SOS edited by Jacky Davis and Raymond Tallis, 2013 is published by Oneworld publications (www.oneworld-publications.com)