Q. What’s happened to the NHS in England?
A: In 2012 there was a major restructuring of the NHS, brought in by the Health and Social Care Act (HSC Act). One of the biggest changes this introduced was to shift legal responsibility for the NHS. The Secretary of State for Health used to have a legal duty to ‘provide’ a comprehensive national health service, publicly funded and provided, and free for everyone at the point of use. Now he or she only has a duty to ‘promote’ such a service. The HSC Act also extended the privatisation of the NHS by turning it into a market and making it subject to European competition law (see http://www.patients4nhs.org.uk/marketisation-of-the-nhs/).
With the HSC Act, most Strategic Health Authorities (the bodies responsible for ensuring that local health systems work effectively) were abolished. Overall control for the NHS passed instead to non-goverment bodies – ‘NHS England’ and ‘Monitor’ (now part of NHS Improvement’) – that regulate Clinical Commissioning Groups (CCGs). It has emerged that some members of these bodies have strong links with private health firms (see for example http://www.dailymail.co.uk/news/article-2109907/NHS-fairness-tsar-urged-quit-doctors-conflict-following-799-000-payment-U-S-private-health-giant.html#ixzz1o8EIqvl8).
Primary Care Trusts (which used to be responsible for buying health care as well as providing some of it through community health services) were also abolished by the Act. Instead 211 Clinical Commissioning Groups (CCGs) were set up across England. Run in theory by GPs, they have a much smaller budget (now £65 billion of the £95 billion NHS commissioning budget) to carry out much of the work that PCTs did, such as planning and buying acute (e.g. hospital) and community services. Some CCGs are also becoming involved now in commissioning primary care services as well.
Each CCG, composed primarily of GPs, will have been authorised by Monitor (the precursor of NHS Improvement) and has a fixed budget to buy healthcare services for all the patients registered with them. All NHS-run service providers now have to compete with private companies for NHS funding.
Because most GPs don’t have the time or skills to plan or buy healthcare services, much of this work was taken over initially by little publicised Commissioning Support Units (CSUs). These not only managed things like human resources, pay roll issues, and patient involvement, but also played an important role in service design and commissioning.
CSUs were initially NHS bodies but were due to become autonomous organisations by 2016. However, in January 2015, NHS England announced what it called the Commissioning Support Lead Provider Framework. This is a list of preferred commissioning services, some of which are CSUs but the majority are private companies such as Capita or Optum. It means that a market has now been created not just for providing but also for commissioning health care services. And it’s now feasible for the same private company to be involved in commissioning and providing a service, raising concerns about potential conflicts of interest and the confidentiality of patient data. (See our page “Commissioning Support Units‘ for more details.
The unelected body NHS England (initially called the NHS Commissioning Board) now runs the English NHS, taking over much of the responsibility and work of the Department of Health. The current chief executive, Simon Stevans, has been described as more powerful than any cabinet minister (Health Services Journal, 25.1.16). His organisation has the power to set out radical proposals to change the NHS without any discussion in parliament and without any explicit political mandate. The 5 Year Plan for the NHS (or Five Year Forward View as it’s officially called, or FYFV) is one such proposal for 2015-2020. It’s being implemented by dividing England into 44 local health economies or ‘footprints’ which are each required to draw up a Sustainability and Transformation Plan, essentially to restructure and cut services in order to deal with deficits and reduced levels of funding.
The FYFV sets in motion another round of radical changes to the NHS. For example, it calls for new ways of delivering care, or ‘new care models’. These can take various forms, but generally will dismantle traditional boundaries, such as between the NHS and social care, between physical and mental health care, and between GP surgeries and hospital care. These ‘new models of care‘ are proposed on the grounds that they will provide value for money and at the same time improve patient experience. They also offer opportunities for private companies to become increasingly involved in commissioning services and sub-contracting providers, including NHS Trusts. There are serious concerns that these models of care are being introduced at great speed and without sound evidence of their benefits. There are also fears that the FYFV more generally is part of a long-term strategy to cut NHS funding and gradually transform the NHS into an insurance-based health care system, similar to that of the US (see our webpage A long term plan).
Q: Was restructuring of the NHS necessary because the NHS was failing?
A: No, or at least not in the way it’s being restructured. Certainly, the NHS has been facing new challenges, such as how to fund care for a growing number of people reaching old age and who may have complex needs (although the burden of costs for caring for this age group have been exaggerated – see www.euro.who.int/data/assets/pdf_file/0004/64966/E92560.pdf). There is also a growing understanding of the need to integrate the NHS and social care. But the way the NHS has been restructured as a result of the HSC Act and the 5 Year Forward View, and the way the NHS is being turned into a market will do nothing to address these challenges.
Accusations that the NHS overspends or under performs, or is unaffordable, were used to justify introducing the Health and Social Care Act and we are seeing these accusations emerge again to explain plans for further massive restructuring (The Five Year Forward View). However evidence suggests that, although there is a need for improvement in some areas, compared with other healthcare systems in the world the NHS does very well in terms of safety, effectiveness, and health outcomes and manages to outperform other, more expensive systems, such as that of the USA. See http://www.nhscampaign.org/NHS-reforms/the-truth-about-our-nhs/the-unreported-nhs-1.html. It’s also clear that health care provided for profit is of a poorer quality while costing more (http://www.theguardian.com/society/commentisfree/2016/feb/09/nhs-part-privatised-health-service-complexity-costs-billions?CMP=share_btn_link).
Public satisfaction with the NHS was, at least until recent cuts, at an all-time high. (www.bmj.com/content/342/bmj.d1836). This is not to say that the NHS is without problems. But there is no convincing explanation from those who have introduced recent restructuring to show how these will bring real improvements. Instead, there is evidence to suggest that this type of massive organisational change will undo recent progress in patient care. www.guardian.co.uk/politics/2011/nov/23/health-bill-nhs-oecd-report
Q: Is the NHS being privatised?
A: Yes. The NHS is still publicly funded and treatment is still free at the point of use, but this does not contradict the fact that the NHS is being privatised. Increasingly, and particularly since the Health and Social Care Act (2012), providers of services will be private companies, taking work away from NHS providers. Many GP practices are now run by companies like Virgin or Care UK. The diagnostic tests (e.g. blood tests) and imaging services (such as X-Rays, CT scans, ultrasound or mammography) that you might be offered as an NHS patient are increasingly provided by private companies – although you might not be aware of this because these companies can use the NHS logo and look as if they are part of the NHS. If you need surgery, it is possible that you will be referred to a private hospital, or if you need care at home this is likely to come from one of the many private companies becoming involved in community care. And a high proportion of the ambulances undertaking transport or emergency care are now run by private companies – albeit carrying the NHS logo.
For maps showing the extent and growth of NHS privatisation in England, see http://www.nhsforsale.info/mapping-privatisation.html .
See also (See also our web pages on how the NHS is being privatised).
In addition, there are a growing number of NHS organisations that are behaving like private businesses (if not creating private companies) and treating private patients within the NHS. NHS Foundation Trusts are now allowed to earn up to 50% (minus £1) of their income from non-NHS sources. While non-NHS income will probably come from a variety of sources (such as car parking fees or work for charities or local authorities) and not just private patients, raising the cap on private income is likely to bring about a two-tier system of hospital care, with private patients having better access to NHS facilities, and NHS patients waiting longer for a hospital bed or treatment. (see http://nhsprivate.wordpress.com)
Q: What does it mean that the NHS has been turned into a market?
The HSC Act (2012) created a competitive market for health services in which the government still provides the funding but no longer has responsibility for providing comprehensive healthcare. Section 75 of the Act, which deals with commissioning services, patient choice and competition, turned the NHS from a predominantly internal market (in which the NHS was automatically the ‘preferred provider’ of services) into a full market (in which NHS-run services have to compete on ‘equal’ terms with commercial service providers). Sadly, the terms aren’t equal because, for example, many private companies seeking to exploit the NHS market have much deeper pockets when drawing up tenders and so have more resources for expert legal staff etc.
The HSC Act, and specifically Section 75, changed the NHS from a social to an economic activity and, as a result, it became subject for the first time to legislation such as European competition law. Now it is competition law (and not, as promised, local decision-making by patients and clinicians) that largely determines the kind of health services we receive. For more details see http://www.patients4nhs.org.uk/marketisation-of-the-nhs/
Q: Will the NHS still provide care for everyone free at the point of delivery?
A: Yes and no. It’s a matter of definitions, and also a matter of events moving quickly. To begin with, NHS care is not ‘free’ but largely funded by the general taxes we pay. It’s free at the point of use (with the exception of some services such as dental treatment, prescriptions and eye tests for most people) but so, in a way, is healthcare covered by a private insurance policy. What distinguishes the NHS from private insurance is that it’s available to all, whatever level of care is required, and traditionally its been available on the basis of need: we all (or almost all) contribute to the NHS’s funding, but we need and therefore use its services to differing degrees.
In 2011, Andrew Lansley, in charge of the getting the HSC Act through Parliament, assured us that “NHS care will continue to be free at the point of use” (see http://www.theguardian.com/society/2011/aug/29/nhs-bill-lansley-wash-hands) . However, the Act ensured that, in future, the Secretary of State for Health will no longer be politically accountable to ‘secure and provide’ a comprehensive health service: by abolishing this duty and instead giving autonomy to CCGs, the Act removed the only control the voting public had over the way that the NHS is delivered.
Because each CCG has the autonomy to use their budget as they think best and to chose which services they will or won’t provide on the NHS, the care or treatment that patients can get on the NHS is beginning to vary from one area to another (the ‘post code lottery’). For the time being, much of the care that is NHS-funded will continue to be ‘free’. However, there is concern that GPs are already under pressure from their CCGs to keep to strict budgets and may therefore make decisions based on staying ‘in the black’ financially rather than on what a particular patient needs. For example, where a CCG budget is not enough to cover all of its patients’ needs, an increasing number of ‘non-urgent’ services, such as hip replacement, fertility treatments, or hearing aids, may well become rationed or no longer available on the NHS (see http://www.telegraph.co.uk/health/nhs/10499703/NHS-is-rationing-knee-hip-and-eye-operations-report-suggests.html).
Already private companies and some NHS Foundation Trusts are offering ‘self funding’ or ‘self pay’ options for patients who are not eligible for treatment under the NHS (see, for example, http://nhsprivate.wordpress.com/executive-summary/private-patient-services/self-funded-nhs-patients/). There is also fear that personal health budgets, currently being offered to some groups of patients, may prove insufficient to cover an individual’s health care and lead to the public acceptance of top-up fees, or a US-style insurance based health care system, in order to cover unmet needs.
In addition, because of financial pressures (or political agendas), there are already suggestions that in the near future, in addition to what we are contributing through taxes, patients may be expected to pay for certain services, such as:
- the ‘hotel costs’ of their hospital stay, as much as £75 per night (http://www.independent.co.uk/news/uk/politics/nhs-funding-crisis-hospitals-may-have-to-charge-patients-for-stays-9778502.html);
- a charge of between £10 and £25 for routine GP appointments (http://www.independent.co.uk/life-style/health-and-families/health-news/25-to-see-your-gp-majority-of-doctors-want-to-charge-patients-for-routine-appointments-8732498.html);
- a £10 per month ‘membership charge’ to fund local initiatives aimed at preventing ill-health (http://www.theguardian.com/society/2014/mar/31/nhs-users-pay-membership-charge).
And in August 2015, the Secretary of State for Health (Jeremy Hunt) hinted that charges for treatment are just round the corner. His comments came after a little-publicised debate in the House of Lords called for an independent inquiry into the future funding of the NHS. And proposals for a cross -party Commission to look at the future of the NHS seem to be running into trouble as fears emerge that this risks becoming a vehicle for privateers (https://www.opendemocracy.net/ournhs/caroline-lucas/why-i-have-removed-my-backing-for-nhs-commission).
Q: Don’t we need to have these ‘reforms’ of the NHS because money is short?
A: First, the national economy of the UK is the fifth-largest in the world, as measured by nominal gross domestic product (GDP). In this context, how much money is allocated to the NHS is a political decision – and the proportion of our Gross Domestic Product spent on health care may not just be lower than the EU average (there is some debate about if this is true) but in any event is declining year on year. The NHS used to receive an annual average increase in funding of 4% but since 2010 there is just a 1% annual increase in real terms.
Second, one of the biggest costs to the NHS is repaying the Private Finance Initiative (PFI) debt taken out by individual NHS Trusts. The Department of Health has agreed 118 PFIs in which private investors finance the building and maintenance of NHS infrastructure, such as new hospitals. The initial cost of these projects currently stands at £11.6. billion. Ultimately, because of the length of contracts, the inflated service charges and the scandalous rate of interest on the debt, the total repayments will be £79.1 billion. As a result, some NHS Trusts are facing bankruptcy. PFI debt is one of the main reasons why NHS Trusts are having to cut services, make staff redundant and sell off assets. However, the ‘reforms’ ushered in by the HSC Act do nothing to address the problem of PFI.
Third, the Government has said that its ‘reforms’ will save money. This is despite the fact that in 2011, a study in the Journal of the Royal Society of Medicine found that over 25 years the NHS was one of the most cost-effective healthcare systems in the developed world (https://www.theguardian.com/society/2011/aug/07/nhs-among-most-efficient-health-services). But besides the expense of restructuring the NHS after the HSC Act (currently estimated as up to £1.6 billion), costs will increase because of the extra layers of management and the extra costs created by a healthcare system based on competition and legal challenges under competition law.
Further restructuring of the NHS in line with the Five Year Forward View will introduce additional costs. So too will the introduction of a seven-day NHS service – if this is to mean elected (non-emergency) surgery, outpatient appointments, diagnostic services (like scans) etc will be equally available and resourced on weekdays and weekends: at the moment, the fear is that providing full services over weekends without additional funding will lead to reduced services during the week. Finally, it’s a myth that the NHS is unaffordable or more expensive than a system of privately run healthcare – see for example, http://www.theguardian.com/society/commentisfree/2016/feb/09/nhs-part-privatised-health-service-complexity-costs-billions?CMP=share_btn_link
Some parts of the NHS are struggling financially. Yet other parts are in surplus. With a national, integrated service, there is scope to redistribute finances. But with the NHS broken into fragments, as it is now, where each fragment is in competition with the others, such redistribution is not possible.
Q: Is the government right when it says that, despite ‘efficiency savings’, frontline jobs and services will be protected?
A: No. The Department of Health admit that 7,060 clinical staff were made redundant after the coalition government came to power in 2010 pledging to protect the frontline of the NHS from cuts: NHS Information Centre figures show that the NHS workforce overall fell by almost 21,000. There has also been a complete freeze on staff recruitment in some areas. According to the British Medical Association’s chairman Mark Porter, staff redundancies were largely the the result of ‘the Nicholson Challenge’ – a £20bn savings drive that since 2011 put ‘arbitrary Treasury spending limits’ above the needs of people’s health needs and population growth. (see http://www.theguardian.com/society/2013/dec/31/nhs-staff-laid-off-amid-savings-drive)
More recently, the Five Year Plan for the NHS calls for a further £22 billion in savings to be found between 2015 and 2020 by encouraging reduced demand on services; introducing ‘new care models’ claimed to be more cost effective; and talk of unspecified ‘new options’ for the workforce, which is expected to be more ‘flexible’. It is hard to see how the level of savings and the means of achieving these will not impact on front line services and front line jobs.
Q: What does it mean to have private businesses providing NHS services?
A: The government justified opening up the NHS to ‘Any Qualified Provider’ (that is, approved private as well as NHS providers of health services) by saying it would give patients more choice over the health care they can get. But NHS health care provided by private businesses is inevitably shaped by those companies’ legal requirement and top priority to make a profit. Compared to the old NHS (in which funding for services did not have to include a profit margin), when private businesses provide health care, shareholders’ dividends have to come out of the funding that service commissioners have allowed for patient care.
There are also fears that private healthcare providers will seek contracts for treating only those patients who create the most profit and the least risk for them (‘cherry picking’), putting the NHS under financial stress by leaving it to cope with those patients – such as those requiring more complex treatments – that companies find less profitable. (For more information, see http://www.nhscampaign.org/NHS-reforms/cherry-picking.html)
In addition, the profit motive can create an incentive for over-treatment. It is difficult for patients to know if the treatments they are being given are really necessary or are being offered because they create profit for the service provider. For example, in the US system, which is similar to the system that we seem to be moving towards, it has been estimated that over 10% of all health care expenditure in 2009 went on unnecessary treatment. www.economist.com/blogs/dailychart/2011/06/us-health-care-spending.
And because companies can claim ‘commercial confidentiality’, little is known about the quality and safety of care provided to NHS-funded patients in private hospitals (https://chpi.org.uk/wp-content/uploads/2014/08/CHPI-PatientSafety-Aug2014.pdf).
Q: Is transforming the NHS all about GPs and other clinicians in charge and, if so, would this be a good thing?
A: No. We were told that the restructured NHS would put those who knew most about the needs of patients (namely GPs, according to the government) in the driving seat. However, the claim that GPs are in charge could be seen for what it was when it became clear that some GP’s decisions about treatments for their patients (e.g that a patient needs to see a hospital consultant) have being examined and possibly overturned by Referral Management Centres. (http://www.guardian.co.uk/society/2012/aug/31/nhs-rationing-risking-lives-doctors-leader) GPs don’t have more clinical freedom but they and other members of Clinical Commissioning Groups (CCGs) do have new responsibilities for balancing budgets and deciding whose care can be paid for and whose cannot. This is less about putting clinicians in charge of shaping our health services and more about making them appear to be responsible for the results of cut backs in funding and the rationing of healthcare that we are now seeing.
There is also a crisis in general practice. Many practices are failing to recruit new salaried GPs or locums. 97% of GPs responding to a survey in 2014 said that their practice was dealing with an ever-increasing and unsustainable workload, while 80% thought their practice would not exist in 10 years. (See https://pracmanhealth.files.wordpress.com/2014/08/are-you-in-despair-for-your-future-in-general-practice-final-report1.pdf). Unsurprisingly, with GPs struggling to manage their day-to-day clinical role, they have little capacity for taking on the work involved in the buying and monitoring of services. In fact, GPs hold only 25% of accountable roles in CCGs, while one in 10 of those who took on such a role when CCGs were first set up have now left (see Judith Welikala, ‘GPs hold only a quarter of accountable CCG roles’ Health Services Journal, 16.10.2014).
In addition, by September 2013, research found that one in five GPs sitting on a CCG board had a financial interest in the very providers that were supplying services to their own CCG. While there was little to suggest wrongdoing, it raised concerns that GPs’ influence on CCG boards was weakened if they had to leave meetings when key decisions were being made to avoid conflict of interest. (See http://www.pulsetoday.co.uk/commissioning/commissioning-topics/ccgs/revealed-one-in-five-gps-on-ccg-boards-has-financial-interest-in-a-current-provider/20004369.article#.VIq7-MJXnGQ).
At the same time, most GPs do not have the management experience or specialist knowledge to undertake the complex processes of commissioning. Increasingly this work is being taken over by non-clinicians (see Commissioning Support Units).
Q: What are personal health budgets and are they a good thing?
A: Personal budgets (PBs) – in some ways a forerunner of personal health budgets – have been available for some time for those who need social care and support in order to live as independently as possible. PBs were introduced on the understanding that giving people more choice and control over the social care services they use would improve the quality of their life. Following an assessment, a service user is given a pot of money to buy the support that they think will help them most. This might be ‘meals on wheels’ or transport costs, for example, but, until now, it’s excluded healthcare.
The, the government introduced the idea of a Personal Health Budget (PHB) or a set amount of money that is allocated to an individual to spend on healthcare. How much money a person is allocated is based on an assessment and care plan drawn up with their ‘local NHS team’. A PHB can then be spent on anything that meets an individual’s health needs (other than GP or emergency services), as long as the health team approves it. For example, a PHB might be used for paying for personal care, for training personal assistants, or for equipment. From 2014, everyone with a long-term condition (such as severe arthritis or multiple sclerosis) who wants a PHB can have one by 2014. The Department of Health (DoH) also plans that, at some point in the future, anyone who feels they can get better healthcare by using a PHB will be able to ask for one.
The government says that PHBs will help people to become more involved in discussions and decisions about their healthcare. They suggest that the greater control and choice that PHBs allow will make patients feel more positive about the care and support they get. However, PHBs raise concerns about the responsibilities that individuals may have to take on (for example, if they have a carer, they will, as their employer, need to deal with tax, and insurance, manage poor staff, and organise sickness cover). It is also unclear what effect PHBs will have for the long-term future of the NHS. For more information, see our page on Personal Health Budgets (which also includes information on the more recent idea of Integrated Personal Budgets).
Q: Is the private sector more efficient at providing NHS services?
A: No. There is no evidence that the private sector is more efficient than the NHS, and in any case it is hard to compare the two sectors because their aims differ. Publicly provided health services exist only to provide health care. In contrast, under company law, private companies have an overriding aim to generate profit, and this is the case whether they are in the healthcare industry or any other enterprise. While staff working for private healthcare providers may be personally committed to the care of their patients, the companies themselves are legally required to prioritise shareholder earnings over benefits to patients.
In addition, examples are now emerging where private companies have taken over health services and made a real mess of things. For example, Circle Health was awarded a 10 year, £1 billion contract to run Hitchingbrooke Hospital in Cambridgeshire. Circle pulled out after three years after telling its investors that it was “no longer sustainable” to manage the hospital, and following warnings from the Care Quality Commission about hygiene failures, staffing problems, poor care (such as patients being sedated without consent) and the emotional abuse of staff.
The health care system in the USA is a good example of how private provision of healthcare is more expensive and less efficient than universal healthcare systems. It creates more opportunities for fraud and over-treatment, and wastes money on advertising, marketing and lobbying. A 2014 study by the Commonwealth Fund found the US healthcare system to be the most expensive in the world, but underachieves “on most dimensions of performance.” Compared to the 11 nations studies, it came last or near last on efficiency, as well as equity and access. Despite spending on average twice as much of its GDP on healthcare as most European countries, the US healthcare system excludes about 20 million Americans and leaves many more perilously under-insured and facing huge debts or bankruptcy if they are hit by serious illness or injury (http://www.commonwealthfund.org/publications/fund-reports/2014/jun/mirror-mirror?utm_source=twitter&utm_medium=social&utm_campaign=).
Q: Will more affluent people be able to rely on private health insurance to pay for any medical treatment they need?
A: No, not always. Medical insurers only insure risk. This means that they require potential customers to tell them about pre-existing medical conditions before they offer cover, and if it’s certain that a condition will require treatment, then that treatment generally won’t be covered by an insurance plan. In addition, conditions that are especially resource-intensive may not be covered (see http://www.euro.who.int/__data/assets/pdf_file/0007/98422/Private_Medical_Insurance_UK.pdf). In the US, depending on the type of cover someone has, they may face crippling bills for health services, even if they have health insurance.
Does ‘going private’ save the NHS money?
Overall, this is unlikely. As mentioned above, private companies tend to ‘cherry pick’ patients who appear to have the least complex problems, which leaves NHS providers to care for those with complex and therefore more expensive issues. Before privatisation, an NHS hospital would have been able to cross-subsidise its different departments and balance its finances by having a mix of complex and less complex work.
In addition to private hospitals not having to report on their performance, many do not have intensive care units to treat patients if problems arise. They do not always have anaesthetists on-call, or senior doctors on duty, or doctors and nurses available with the right qualifications, especially in the case of emergencies. When problems arise, patients have to be transferred to the NHS (where, e.g., a poor outcome due to the shortcomings of the private hospital becomes a blot on the NHS hospital’s record) (https://chpi.org.uk/wp-content/uploads/2014/08/CHPI-PatientSafety-Aug2014.pdf). Plus, unlike NHS providers, private hospitals make little contribution towards the training of the health care professionals that they attract from the NHS.
Q: Is competition good for encouraging innovation and enterprise, or for raising quality?
A: Competition may be good for markets in consumer goods, but competition does not raise quality or encourage innovation in health care. Caring for patients, particularly those with complex conditions, requires co-ordination and information sharing between providers. However, where providers are in competition with each other, legal restrictions on information-sharing and collaborative problem solving work against innovation and enterprise. The more recent focus on ‘integrated care‘ may in part aim to address some of these issues but there is little evidence so far about how successful it is.
Q: Massive reorganisation of the NHS is already being implemented and some politicians have said it is too late to reverse privatisation of the NHS. Is it best to just keep going now?
A: No. Politicians behind the Health and Social Care Act (2012), a number of whom have a personal, financial, or career interests in seeing the NHS privatised, have said that it is too late to turn back. (see http://www.mhpc.com/health/beyond-bill-will-health-and-social-care-act-ever-be-repealed/). There are also suggestions that, now that the NHS has been opened up to competition and is no longer entirely publicly provided, privatisation may be difficult to reverse: the interests of the companies involved may be protected by European competition law or the investor protection measures included in various trade agreements (see our page on free trade agreements). At the same time, many NHS staff feel overwhelmed by the scale and pace of change taking place and would not be in favour of further change. But all this has not stopped NHS England introducing its Five Year Plan that will massively restructure the NHS yet again and have enormous implications for its workforce.
Cumulatively, these changes – particularly since 2013 – are fragmenting and destabilising the NHS, suggesting that reversal of the HSC Act is the only option if the NHS is to survive. And on that note, optimists believe it should be relatively easy to get rid of the requirement for CCGs to buy services from outside the NHS, and to stop NHS Improvement from enforcing competition. In addition, the campaign for an NHS Reinstatement Bill aims to restore the NHS to an accountable public service without major organisational change.
At the same time, it’s clear that if free trade agreements like the one currently being agreed between Canada and the EU (CETA) are settled without health services being fully excluded, or if these include an Investor State Dispute Settlement mechanism (ISDS), it will be more or less impossible to reverse the privatisation of the NHS for many years: (see our section on free trade deals for more details).
Q: What is meant by a seven day NHS?
A: It’s not clear. Before the 2015 election, David Cameron promised to create “a truly seven-day NHS” explaining that, in hospitals, this meant “It’s about different shift patterns, so that our doctors and nurses are able to give that incredible care whenever it is needed.” And “It’s about key decision makers being around at the weekend; junior doctors being properly supported and resources like scanners up and running wherever they are needed” (https://www.gov.uk/government/speeches/pm-on-plans-for-a-seven-day-nhs). Since then, the Secretary of State for Health has been pressurising junior doctors to agree a new contract that (along with other changes) would see them working evenings and weekends as part of their normal duties (i.e with a reduction in unsocial hours payments). His argument is that, according to some studies, patients admitted over a weekend have an increased risk of death. Critics suggest that this is because patients who need non-routine admission on a weekend are particularly likely to be severely ill.
It’s been estimated that if a seven-day NHS means providing routine services every of the week, this will require an additional 11,000 NHS staff, as well as resources such as diagnostic services, social care, transport services and administrative support. The cost is likely to be an additional £900 million each year. It is unclear where the additional money or staff will come from and there are fears that, ironically, to provide a ‘seven day NHS’ will mean the closure of some services (http://www.theguardian.com/society/2016/feb/15/weekend-effect-on-hospital-deaths-not-proven-say-hunts-own-officials).
What are Sustainability and Transformation Plans (STPs)?
A: Good question: draft STPs were developed under a cloak of secrecy. They aim to implement the restructuring of the NHS set out in NHS England’s Five Year Forward View (FYFV). This involves the setting up of 44 new ‘local health systems’ or ‘footprints’ across England, consisting of ‘clinicians, patients, carers, citizens, and local community partners including the independent and voluntary sectors, and local government through health and wellbeing boards’.
Each ‘footprint’ has to draw up a STP to show how they will take over all areas of activity currently commissioned by CCGs and NHS England, including specialised services and primary medical care. They also have to show how they will ensure better integration with local authority services, including prevention and social care. But essentially, STPs have to show how the ‘footprint’ will
- cut expenditure and stay within budget by, for example, reducing the number of patients using in-patient and GP services, reducing the pay bill, or reducing the number of hospital beds, and generating income (potentially from private patients or selling land). Saving money (rather than patient safety) is the first priority.
- maximise efficiency by patient demand for services by increased emphasis on prevention and the introduction of new ways of delivering services, including new models of care (such as Multispecialty Community Providers) proposed by the FYFV.
These plans had to be drawn up at great speed and submitted to NHS England – initially by June 2016, for implementation in the autumn, – but the deadline has now been extended. NHS England has said that once it has approved an STP it will then be made available for public comment. However, the original timescale suggests that public consultation on major service changes is merely being given lip service. (For more details see our page on STPs)
In a motion put to the House of Commons by the Shadow Secretary of Health in September 2016, she said that
- STPs would lead to significant cuts or changes to frontline services;
- the process agreed by the Government lacks transparency while the timeline is insufficient to finalise such a major restructure of the NHS; and
- the timetable does not allow for adequate public or Parliamentary engagement in the formulation of the plans.
The King’s Fund, a leading think tank, has said that it expects the cuts made under the STPs will be “eye-watering”. Others, such as the leader of Hammersmith and Fulham Council, have said that STPs are about breaking up and selling the NHS.