This is a cross post by Dr Mike Squires from The Patient Experience
Andrew Lansley’s Health and Social Care Bill promises the biggest shake up ever seen in the NHS.
The Bill, at over four hundred pages, is even larger than the legislation that set up the NHS over sixty three years ago.
What does the Bill, if it becomes law, hold for patients and the public? The view of most healthcare professionals is- not very much. The NHS Consultants Association, the British Medical Association, the Royal College of Nursing, and the two major hospital unions, Unison and Unite, have all given the Bill a massive thumbs down.
What motivates this fear of Lansley’s reforms amongst informed medical opinion?
At the very heart of the legislation is the idea that services previously carried out by the NHS should now be open to the private or independent sector. The BMA, with its watchword of an ‘NHS Publically funded and Publically provided’ is bound to give this approach short shrift.
Doctors are sceptical of opening the NHS up to private companies, who will undoubtedly opt to tender for the simplest and most profitable services, which would have a destabilising effect on the hospital structure. Allowing private companies to tender for services previously performed in an NHS hospital will lead to the closure of departments and ultimately to hospital closures.
Putting profits first before patient welfare is a widespread concern that is shared by all healthcare organisations.
One of the Bill’s big selling points and much referred to by Andrew Lansley, is that GPs will now be the major recipient of NHS funds. The envisaged Commissioning Consortiums of GPs will be free to buy in services according to local need.
For some more entrepreneurial doctors this argument has worked-and some are already beginning to build for themselves little empires consisting of numbers of GP practices.
Most GPs are bewildered by the proposals and the organisations that represent them remain opposed.
Almost lost in the mist of the battle to defeat the bill is the £20 billion worth of cuts that will affect the NHS over the next four years. Cleverly the government has handed over this poison chalice of cuts to the GPs who will be forced to make savings of 5% year on year until 2015.
In future, instead of Primary Care Trusts buying services from hospitals and other providers at a tariff, this task will fall to the new commissioning groups of GPs.
This purchaser/provider split in the NHS, the brainchild of Margaret Thatcher was first introduced in 1990. It created a market whereby one part of the NHS, the Primary Care Trusts purchased services from the other, mainly hospitals.
This created a massive bureaucracy which accounts for about 14% of the NHS’s total budget-£14 billion a year-(House of Commons Select Committee on Health, Report on Commissioning 30 March 2010)
This largely administrative task of purchasing services will not be done by GP but by specialist companies employed by them. The aim will be to curtail to a minimum all hospital referrals which will have to be paid for out the Commissioning Group’s budget.
To do this Management Referral Centres are already being established to scrutinise all GP referrals.
In future, if Lansley’s Bill goes through, it looks likely that the old non commercial doctor patient relationship will be put under a severe strain. A GP may refer a patient to hospital but this could be over-ridden by the decision of the local Commissioning Group’s Management Referral Centre.
Lansley’s proposals not only affect GPs and their patients they will also have a major impact on NHS hospitals.
All hospitals must become Foundation Trusts -many hospitals already are.
Foundation Trust status gives a hospital greater independence and many hospital trust boards see it as a way of allowing development and raising money without having to resort to the extraordinary expensive scheme known as the Private Finance Initiative.
The selling point of FT hospitals has been that they are locally controlled and democratic. This would not appear to be the case.
FT Hospitals are run by an unelected Board of Directors. There is a lower tier called a Board of Governors which includes elected members but they appear to exercise no real control.
Unlike non FT hospitals the Board of Directors do not have to meet in public.
The recent scandal around the Mid Staffs Hospital was, according to the enquiry, due in part to the secrecy that surrounded the hospital administration.
Foundation Trust hospitals will, if Lansley has his way, have the power to opt to become social enterprises-from there it would be a very short step to becoming private.
Hospital services would appear to be the most vulnerable of all sections of the NHS. The Health and Social Care Bill would allow for ‘any willing provider’ to tender for services.
At the moment there is a cap on how much income can be earned by an FT hospital from private patients. Lansley’s intention is to remove this limit.
This suggestion has already provoked a strong condemnation from the usually moderate Hamish Meldrum of the BMA. He argued that Lansley’s proposal would lead to longer waiting times for NHS patients. Given that the current vogue is not to refer patients to hospitals unless absolutely necessary, there seems no reason to disbelieve Meldrum’s assumption. Cash strapped hospitals that rely on GP referrals will be looking for a way to increase their income and private patients are an easy and lucrative option.
Another major concern around the legislation is that it will lead to the decline of roughly equitable standards. GPs in their commissioning groups will be able to purchase services from a range of providers. A service purchased in one commissioning area may not be available in another. The situation could well become even worse than the present much despised postcode lottery.
If the Health and Social Care Bill is the final nail in the coffin of a National Health Service publically funded and publically provided to use the BMA’s terms, the danger that the NHS would disappear under a welter of privatisation has been with us for some time.
Since the introduction of an internal market in 1990 there has been a steady encroachment by private companies on services previously provided by the NHS. Cleaning, catering, patient transport, some medical services are now the preserve of the private sector. Lansley proposals will merely accelerate a process that has been underway for some time.
To stop the privatisation agenda in its tracks is the objective of ‘Keep Our NHS Public’- an organisation formed in 2005 by a broad alliance of trade unions, doctors, the NHS Consultants Association etc. In the six years since its formation the organisation has grown in strength and influence. One of its major achievements has been to persuade the normally conservative BMA not only to oppose Lansley’s Bill but to campaign against it.
Despite the Health Secretary’s constant reassurances that his Bill does not mean the privatisation and ultimate destruction of the NHS, many remain unconvinced.
If the NHS does disappear then Aneurin Bevan’s prophetic words will come back to haunt us.
“It(the NHS) will last as long as there are folk left to fight for it”