Read NHS for Sale: Myths, Lies & Deception Online
Authors: Jacky Davis,John Lister,David Wrigley
NHS for Sale: Myths, Lies & Deception (9 page)
Thus began the process of marketising the NHS, for which political intervention was required. As Paul Corrigan (Alan Milburn’s health advisor) remarked
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– The state has to actively create a market, they don’t appear of their own account. Politicians always justified the policies required as a drive for more patient choice, to be achieved through increased competition. The public was introduced to a lexicon of weasel words to explain the changes. Competition was downgraded to ‘contestability’, while the scrum of private companies descending on the NHS was reassuringly described as ‘a plurality of providers’. ‘World class commissioning’ would make the NHS more ‘patient-centred’. The process was misrepresented, concealed behind a screen of vaguely comforting but meaningless jargon, all intended to divert the public from what was really going on – politicians were turning the NHS into a market, with health as its commodity, and open to the private sector who were after their holy grail, the guaranteed funds of the NHS budget.
It is not surprising therefore that patient choice, ostensibly as wholesome and desirable as motherhood and apple pie, began to be viewed with distrust by many who understood how the concept was being abused to justify the creation of an NHS market. ‘Patient choice’ has been used by successive governments as the Trojan horse to facilitate the introduction of the private sector into the NHS, and ironically the more politicians have championed it the less of it there has been.
The HSC Act has opened the door to a full-blooded market in the English NHS but the story of competition and establishing a market goes much further back.
The covert conversion of the NHS into a business started with the Griffiths report in 1983 (see separate box). Then in January 1988 (in the midst of a serious ‘winter crisis’ triggered by spending cuts in the aftermath of the 1987 general election) Margaret Thatcher used an interview on television to announce that she was going to conduct a ‘review’ of the NHS. There was widespread trepidation, since her major confrontation with the miners in 1984 had been preceded by a ‘review’ of the coal industry. Her NHS review was even more secretive and exclusive and only a small circle of chosen Thatcher supporters was involved. Just over 12 months later on 31 January 1989 Margaret Thatcher made a speech announcing the outcome of the review: a new NHS White Paper ‘Working for Patients’.
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In it she said: ‘We aim to extend patient choice, to delegate responsibility to where the services are provided.’
In 1983, at the height of the Thatcher administration, Roy Griffiths (a director and deputy chair of the Sainsbury’s supermarket chain from 1968-1991), was asked to write a report on NHS management. The Griffiths Report consisted of just 24 pages of assertions without any supporting evidence and called for a major change: Griffiths recommended that the Secretary of State should set up, within the Department of Health and Social Security and the existing statutory framework, a Health Services Supervisory Board and a full-time NHS Management Board
At local level, general managers should be introduced throughout the NHS.
This was a move away from the old management structure and began the process of replacing administrators who were steeped in the values of the NHS with managers who might be drawn from outside the NHS, including the private sector. This in effect started the NHS down a path of seeing itself as a business.
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Interestingly the 1983 Griffiths Report also called for GPs to get more involved in budgets and commissioning of services – a trend that culminated in Lansley’s White Paper of 2010.
For his ‘services to the NHS’ Griffiths was rewarded with a knighthood in 1985.
So began the 25-year non-evidence-based experiment which has attempted to turn the NHS into a market-based system, and the emphasis on choice as a justification for these market-based reforms has been a constant theme of politicians ever since. Thatcher went on to say: ‘All of the proposals in this White Paper put the needs of patients first … the patient’s needs will always be paramount.’
Thatcher’s reforms were pushed through Parliament in 1990 (despite very substantial opposition, including a major advertising campaign by the BMA) as the National Health Service and Community Care Act. This created a new ‘internal market’ in the NHS by dividing up the previously integrated District Health Authorities and by separating off hospitals, mental health and other services, which were expected to ‘opt out’ of direct NHS control and become NHS trusts. The Health Authorities themselves were to be set up as ‘purchasers’, and given the budget to buy services from ‘providers’ on behalf
of their local population. Another aspect of the reforms was to give GPs (who then became ‘GP fundholders’) their own budgets to purchase services for their own patients. This handed budgets directly to larger GP practices to allow them to go out to the marketplace and buy services such as blood testing or knee replacements. The whole effect was to introduce the ‘purchaser provider split’, essentially a primitive market in which health authorities and some GPs held the budgets to purchase care from ‘providers’. At this stage the market – for all its divisiveness and extra overhead costs – was ‘internal’ to the NHS, and virtually none of the money for clinical care was being diverted to the private sector.
John Major’s government published The Patients’ Charter in 1991 (revised in 1995). This affirmed the right of every citizen to be referred to a consultant, acceptable to the patient, when the patient’s GP felt it necessary. Although the Charter was seen as weak overall, it helped to establish the importance of putting patients at the centre of care.
Choice was not an immediate priority for the new Labour Government when it came to power in its landslide win in 1997. However in 2000 Alan Milburn, as Health Secretary, signed a ‘Concordat’ with private hospitals under which the NHS would pay (up to 40 per cent above the NHS cost) for the treatment in private wards of waiting list patients whose operations had been delayed due to winter pressures. This was a ‘choice’ to be made by the NHS rather than the patient.
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It was not until 2002 that plans were announced to offer patients who were already on waiting lists opportunities to choose alternative providers. Milburn was again the chief architect of this, advised by Simon Stevens, now the Chief Executive of NHS England.
It was at this time that ‘patient choice’ began to be referred
to as a policy objective in its own right. At the same time, the government changed the system of hospital payment, to support the policy of patient choice. Payment by Results (PbR)
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introduced a fixed tariff payment per case treated and was a further mechanism for diverting NHS money to the private sector.
PbR was, in theory, supposed to be a way of creating strong incentives for hospitals to raise income by attracting and treating more patients. However it was also a way to ensure that any patients who ‘chose’ or were induced to seek treatment from a private provider took the money with them out of the NHS. This made possible the division of what had previously been ‘block contracts’ between purchasers and provider trusts, often covering the whole local population. In this way PbR deliberately destabilised NHS trusts, leaving them uncertain how many patients they would treat and therefore how much money they could expect to receive to pay staff and suppliers
By contrast the contracts for Labour’s new invention, ‘Independent Sector Treatment Centres’, purpose-built small scale private units, owned and run by mainly overseas for-profit providers, were unbelievably generous. The ISTCs were given five-year contracts, far longer than any NHS hospitals could hope for, and guaranteed numbers of patients, regardless of how few chose to use the new units, with a special tariff price averaging 11 per cent above the
going NHS rate for each job.
The Blair government, egged on by Milburn, Stevens and others, was artificially creating a new market in health care by preferentially favouring these new for-profit providers. NHS trusts were even forbidden from bidding for the ISTC contracts, and negotiations on many of the deals were taken out of the hands of local purchasers and conducted at national level by Department of Health bureaucrats. When members of one local Primary Care Trust objected to a deal being done on their behalf and without consultation, the objecting board members were abruptly removed.
By the time the Labour Government lost power in 2010, the concept of patient choice in the NHS was firmly established. In May 2010 the coalition government launched their white paper ‘Liberating the NHS’ in which competition and choice were inextricably linked. Choice lay at the heart of the proposals but could only be had through competition. Competition in turn required a plurality of ‘Any Willing Providers’ which meant an expanding role for the private sector. The market had won out in a one-sided argument, and choice was its sharpest weapon.
The Health and Social Care Bill introduced the concept of ‘Any Willing Provider’, which allows private companies and other non-NHS bodies to bid for lucrative NHS contracts. In theory to qualify they must satisfy a bureaucratic and cumbersome process, which is a burden for any small charity or third sector organisation to navigate but suits
large multinational organisations perfectly. The term ‘Any Willing Provider’ was quietly changed with no fanfare to ‘Any Qualified Provider’ (AQP) to try and make the process sound more professional and less like a free for all in the NHS contract bidding process.
Many CCG websites explain to the public that AQP is ‘a work programme that will enable the Government to fulfil its commitment to
increase choice and personalisation
in NHS funded services for patients and the public’. Andrew Lansley himself, speaking to a 2011 conference of GPs said: ‘Of course, patient choice implies competition … there are areas where there is already strong demand for more choice – such as community services. This is where we will begin to introduce any qualified provider.’
The Department of Health lists the strategic aims of AQP as to:
- Increase choice and access of health service providers for patients.
- Improve quality and outcomes of health services.
- Drive innovation and efficiency of health service.
Most campaigners, remembering the multitude of new, low quality cleaning and other companies which set up to cash in when the Thatcher government opened up hospital cleaning and other ancillary services to competitive tendering back in the mid-1980s see AQP as a tool to allow profit-seeking companies large or small to take over NHS services.
Patient choice should of course be at the heart of health care but it must be the choice that patients really want, not a spurious version that only serves the aims of the private sector. Most patients for instance want a good quality, local and responsive NHS available to treat them for their general ailments when necessary. Many patients accept they will have to travel further afield for very specialised care but the principle of a high quality district general hospital close to home is one cherished by most people in the UK. It is deliverable by the NHS, and affordable despite all the protestations of politicians and captured think tanks. Perversely the fragmentation and privatisation of the NHS resulting from the HSC Act, along with cuts and closures, threaten this most basic of patient choices. All over the country groups of campaigners are organising to protect local services and struggling to make themselves heard
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– a travesty of Lansley’s promise that there would be no decision about you without you, and a denial of patient choice on a grand scale.
At the same time the genuine patient choice that existed in the first decades of the NHS has been eroded by the very mechanisms that were recently introduced allegedly to promote it. Originally GPs could refer patients anywhere and to any other doctor working in the NHS. With the introduction of the market such referrals are increasingly tied to the contracts that CCGs enter into, with special arrangements required for patients who wish to be seen elsewhere. The following illustration appeared in the comment columns of the
Guardian
in November 2013:
Following a disastrous A&E experience at Hinchingbrooke Hospital (and our closest A&E at Kettering being under a
‘black notice’ due to staff shortages), we ended up at Bury St Edmunds A&E who diagnosed my partner as requiring surgery on her knee. We arranged through the consultant at Bury for the surgery to be carried out at Addenbrookes by a surgeon who had already performed similar surgery on my partner’s son with spectacular success.
All well and good until we were summoned by a GP at a [Northamptonshire] Practice … where we were told in no uncertain terms that the operation would be carried out by a surgeon at Milton Keynes who is not even a specialist in this area.
The reason given – ‘this is who my contract is with’. When we then questioned what would happen if we went to Addenbrookes anyway, we were told we would have to fund the surgery ourselves. He delivered this information with a poster headed ‘NHS Choices’ taped to the wall behind him.
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Patient choice is also seriously threatened by CCGs’ use of referral management centres, designed to reduce the number – and thus the cost to CCGs – of patients being referred to hospital for specialist opinion. Referral letters, written to specialists by GPs who know and will have examined their patients, may be redirected to less specialised services, queried and thus delayed or simply declined by staff who may have little or no clinical experience. This not only makes a mockery of the promise of more patient choice but is clinically dangerous, with examples of delays to patients needing urgent specialist opinion and treatment. At the same time Jeremy Hunt, in a spectacular failure of joined up thinking, is threatening doctors who ‘cost patients’ lives by failing to send them for vital hospital tests soon enough’.
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