Before the 2010 election Cameron promised that he would cut the deficit and not the NHS, and that there would be no more top down reorganisations. He quickly broke these promises and the Coalition attempted to justify their massive ‘reforms’ with a series of myths and lies about the NHS. These have become received wisdom despite the fact that they are manifestly untrue.
The English NHS is under attack as never before, with the government briefing against it at every opportunity and aggressively pushing a privatisation agenda. But the NHS wasn’t broken and didn’t need fixing. When the Labour government left office, the NHS had its highest ever popularity ratings. After investment in the service, waiting lists had come down and outcomes were improving rapidly. There was every reason to believe that a public, accountable NHS could continue to evolve, improve and meet the challenges of the future, including care for an ageing population. Instead the ‘reforms’ have plunged it into organisational chaos and financial instability, and the patients are the losers.
International studies have consistently shown the NHS to be one of the most cost-effective health services in the world. In 2014 the Commonwealth Fund study ranked it highest overall based on quality of care, access to care, efficiency and equity. Among the 17 countries considered, the US healthcare system was among the least efficient and effective.
If we are agreed – and most people are – that the state has a role in providing health care, then the NHS is doing a good job with our money. And politicians who claim we can’t afford the NHS must answer the question – if we can’t afford the most cost-effective health service in the world what can we afford?
Politicians claim they are not privatising the NHS, but one tenth of GP surgeries are now privately owned, and contracts worth billions of pounds have been given to the likes of Virgin and Serco. Recently huge contracts have gone to private companies including one for £780 million to catch up on the backlog of patients waiting for surgery and diagnostic tests. 3 of the companies involved have already been severely criticised for delivering poor care to NHS patients.
Politicians quote statistics showing a low percentage of the overall NHS in the hands of the private sector, but the private sector does not want to run much of the NHS because they can’t make a profit from it. In the areas in which they are interested – typically elective surgery, community health and mental health – they have a high proportion of the contracts (recent figures suggest up to 60% in community and mental health). The public does not want this – polls show that the majority of people want local and national government to run public services, and only consider contracting out if this fails. People also want accountable health care, while private contracts hide behind ‘commercial confidentiality’. The chair of the House of Commons public accounts committee, Margaret Hodge, says that even she can’t break through their wall of secrecy. Because contractors may go on using the trusted and familiar NHS logo, patients may not even know they’re receiving treatment from a private company.
There is not a scrap of evidence that the price goes down and efficiency increases when private companies deliver NHS care. In fact, all the evidence points the other way. Costs increase and services may well get worse as the private sector typically cuts and/or downgrades staff and reduces the services on offer . The fiasco of hospital cleaning has shown the reality of privatisation: apparent short-term savings, but at the expense of lower hygiene standards, higher rates of hospital-acquired infection, the break-up of established ward teams and casualisation of the workforce.
Companies such as Serco have been heavily criticised for the poor standard of the service they have delivered. Serco has now withdrawn from clinical services, preferring to concentrate on the more lucrative work of providing admin for the NHS market . Other recent failures have included a contract for cataract surgery that had to be terminated after a few days because of disastrous outcomes, and the discovery of unexplained deaths in private hospitals delivering care to NHS patients
The Health and Social Care Act was never about cutting bureaucracy, though that argument helped to get Lib Dems on board and push the massive bill through parliament. Today we have a bigger bureaucracy that consumes more time and resources. The 150 primary care trusts have morphed into 211 ‘clinical commissioning groups’ (CCGs). Much of the CCGs’ work is outsourced to ‘commissioning support units’ (CSUs), to be performed by people the NHS does not call employees, and who are not subject to the Freedom of Information Act. By 2016 these services will have been put out to competitive tender.
CCGs and CSUs are monitored by a new national bureaucracy, NHS England, which employs 4,000 people and has 27 local area teams that don’t meet publicly or publish papers. Among the other tiers of bureaucracy are the health and wellbeing boards, Healthwatch England, toothless local Healthwatch patient groups (which are forbidden to conduct any ‘political’ campaigning), citizens’ panels, clinical senates and dozens more. The new bureaucracy is less accountable and the Royal College of GPs has described the new lines of accountability as looking like ‘spaghetti junction’.
As a direct result of the ‘reforms’ the NHS is now less cost effective. Money is being wasted on running the English NHS as a market, in which hospitals have to compete rather than cooperate and GPs (contrary to the promises that were made by Lansley) are legally required to spend money on expensive and lengthy tendering processes. The proportion of the NHS budget spent on administration has increased dramatically, rising from around 6 per cent to around 15 per cent (the government won’t tell us exactly how much). Running the English NHS as a market is estimated to cost between £5 and £10 billion/yr.
Large amounts of money are being lost through PFI, with tax payers getting about £11bn infrastructure for an eventual cost of over £70b. These PFI debts are crippling many of the hospitals involved. Meanwhile the Treasury has clawed back about £5b from the NHS at the same time that the service has suffered rationing, bed closures and staff cuts. If we abandoned the costly and unnecessary market and dealt with the outrageous and unfair PFI debts, we would save billions for frontline care.
Patients have less choice now than they did 20 years ago, when a GP could send a patient to any part of the NHS anywhere in the country. Now GPs may be constrained by the contracts they have with providers. Many GPs are now given targets to lower their referrals to hospital. Referrals may pass through a management centre where they are checked and may be redirected by people with little or no clinical training and no knowledge of the patient. One in eight referrals is rejected altogether. Operations once available from the NHS, such as joint replacements and hernia repairs, are increasingly being rationed or withdrawn.
‘Choice’ has been used as a Trojan horse to introduce the market, but market ‘competition’ is unlikely to result in diversity. Large companies have the resources and expertise to win expensive tendering processes for NHS contracts, crowding out NHS workers and small social enterprises. 67% of contracts have been won by non NHS providers since 2013. If this continues we face the possibility of quasi-monopoly private providers, who have more talent for winning contracts than for running clinical services. The private sector also has no obligation to provide a full range of services, so it cherry picks the ones it sees as profitable. Any replacement of local NHS providers by private companies can result in reduced services and gaps in care for vulnerable patients. And outsourcing the profitable work to private companies destabilises the local NHS which may not be able to continue to deliver the expensive and complex work which the private sector doesn’t want. We have already seen this with the contracting out of dermatology and musculoskeletal services
Polls show 73 per cent of GPs now believe they have been set up to take the blame for rationing health care. Far from being in charge, GPs are effectively rubber stamping decisions imposed by NHS England and commissioning support services. Only a third of GPs are actively involved with the work of CCGs, and of those who are involved, more than a third have links with or shares in private medical companies and insurers.
There has been an unprecedented collapse in morale in general practice, with 6 out of 10 GPs considering retiring early. According to Dr Maureen Baker (chair of the RCGP) general practice is ‘on the brink of extinction’
Local consultations have been consultations in name only. Petitions with thousands of signatures have been ignored. After Lewisham’s local hospital was sacrificed – to bail out a nearby trust crippled by a massive PFI debt – community members had to take Jeremy Hunt to court to overturn the decision. When he lost he changed the law to make it easier in future to close hospitals without consultation.
The government’s willingness to go against local people is deeply undemocratic, and the more rhetoric there has been about patient voice the less genuine engagement there has been. The proliferation of NHS campaigns and local action groups is an indication of the fact that many people feel they have little option but to take to the streets to be heard.
The reforms ended the duty of the Secretary of State for health to ‘secure or provide’ a universal and comprehensive health service in England. There are now confused lines of accountability and the SoS for health can criticise the NHS without offering solutions or acknowledging responsibility for problems arising from government policy.
New bodies created by the reforms do not have to meet in public or publish their minutes. The commercial sector hides behind ‘commercial confidentiality so that we the tax payers can’t find out the most basic facts about their costs, profits and outcomes
The most reliable figures suggest that unrecovered costs from treating foreign nationals account for less than 0.2 per cent of the NHS budget. The government has encouraged scaremongering as a useful distraction from the real problem of £20 billion in cuts to the service.
Cameron promised he would cut the deficit not the NHS but this turned out to be another lie. By October 2104 66 maternity and A&E units had been closed or downgraded and 8649 beds had been lost. ‘Reconfiguration’ has become a dirty word with the closure of A&E departments often the prelude to downgrading and closing of hospitals
Jacky Davis is co author (with John Lister and David Wrigley) of a new book NHS For Sale. It debunks the Coalitions myths and lies about the NHS and shows how the reforms have plunged the service into chaos.