“We made three mistakes that I regret, the first being restructuring the NHS. The rest are minor.”— unnamed Senior Conservative Cabinet Minister
Until now, the NHS has been remarkably efficient in providing health care. A report on the health care systems of 11 countries by the Commonwealth Fund found that the healthcare provided by the UK’s NHS was superior to that provided by countries which spent far more on health (including the USA in which private healthcare providers are the norm). The report concluded that the UK came first overall, scoring highest on effective, safe and patient centred care, access to services and efficient use of resources, and out-performing the other countries in its care for people with chronic conditions. This high rating was despite spending the second-lowest amount on healthcare among the 11 countries. (See http://www.theguardian.com/society/2014/jun/17/nhs-health.)
The Commonwealth Fund study reported in 2014, probably drawing on data collected before any effects of the HSC Act and financial cuts had become evident.
A recent review of 33 studies that looked at the provision of NHS services by private companies has found that, for the most part, introducing competition into the UK’s NHS brought negative results. The review found a lack of evidence to show that private provision of NHS services led to improved quality of patient care. Outsourcing cleaning services had a negative impact on patient care, while outsourcing of clinical services (e.g. the provision of GP ‘out of hours’ services by private companies) showed ‘negative effects’ on patient care, poor value for money and lack of adequate monitoring and evaluation of services. http://www.psiru.org/reports/broken-promises-impact-outsourcing-nhs-services
Looking at a 2014 report on the only privately-run NHS hospital (Hitchingbrooke in Cambridgeshire) by the Care Quality Commission (CQC) provides more of a sense of what such ‘negative effects’ might be. The hospital was taken over by Circle in 1212 in a ten year contract worth about £1 billion. Concerns of the CQC included poor management, inadequate hygiene, and poor patient care, such as the treatment of patients in an undignified or emotionally abusive manner, with some patients on medical wards who lacked the capacity to consent being restrained by the use of sedation (see http://www.theguardian.com/society/2014/sep/26/care-quality-commission-hinchingbrooke-hospital). Circle pulled out of its contract after three years, telling its investors that it was “no longer sustainable” to manage the hospital.
Many clinicians (that is, doctors and other health care practitioners such as nurses, physiotherapists and midwives) have expressed deep concern about the effects of the HSC Act. Most Royal Colleges representing clinical staff – including the body representing GPs, the doctors expected to make the restructured NHS work – tried to stop the HSC Act becoming law once they realised what the legislation would mean.
Of those who supported the ‘reforms’, some (mostly doctors) clearly benefit from the changes. For example, when Harmoni – an ‘out of hours’ service – was sold to Care UK, GPs involved in the company (at least one of whom was a great champion of the reforms) shared more than £25 million of profits. (http://www.telegraph.co.uk/health/healthnews/9668756/GPs-cash-in-on-sale-of-out-of-hours-provider.html).
Some GPs who are involved in this kind of private enterprise have been concerned about the conflict of interest that they face. For example, under its former name Assura, Virgin had set up 24 local “provider companies” offering patients community services such as dermatology, physiotherapy and rheumatology. All of these services were run as partnerships with local GPs. In the end, more than 300 GPs ended their partnership with Richard Branson’s Virgin Care when it became clear that this might lead to doctors profiting personally from sending patients to clinics that they part-owned (see http://www.guardian.co.uk/society/2012/oct/24/doctors-virgin-partnership-conflict-of-interest?CMP=twt_gu ).
The government argued that competition between health care providers would lead to cost efficiency and improved quality of care – even though it was already clear that the savings promised by previous governments through privatising hospital cleaning were often at the expense of lower standards and increased hospital-acquired infections. Since then the evidence is mounting that competition does not reduce costs, not least because of the (new) expense of putting all services out to competitive tender, estimated at between £4.5 billion and £30 billion a year. (www.opendemocracy.net/ournhs/caroline-molloy/billions-of-wasted-nhs-cash-noone-wants-to-mention). For more details of the costs of competition, see our page on turning the NHS into a market.
First, arguments that the NHS is becoming unaffordable have to be viewed with caution. The UK spends less on health care than many other countries. For example, from 1977, the UK has spent less of a share of its GDP on health than either the EU average or the average for countries of the Organisation for Economic Co-opertion and Development. We spend about half as much as the US on health care (http://www.nuffieldtrust.org.uk/data-and-charts/uk-health-spending-share-gdp).
In addition, claims about demand can be misleading. For example, it is often cited that the NHS is becoming unaffordable because people are living longer. But older people are fitter and healthier than in previous decades, they contribute more to the economy than they take out, and account for a relatively small amount of any increase in spending in recent years (http://nhsbill2015.org/wp-content/uploads/2015/03/Myth-of-Ageing-fact-sheet.pdf).
Second, the ‘reforms’ are not necessarily about addressing rising demand and treatment costs. This is particularly clear with the Health and Social Care Act which did nothing in this respect: it was much more focused on restructuring the NHS and making competition mandatory in order to allow increasing levels of privatisation. The Five Year Forward View (FYFV) calls for a variety of measures (e.g. increased patient ‘self care’, initiatives to prevent ill health, £22 billion of efficiency savings, a ‘flexible’ workforce and new models of care that control costs) to close the gap it calculates between demand and funding. However, it ignores some of the significant drains on NHS funding, such as the Private Finance Initiative and the costs of running the NHS as a market, suggesting there is some other agenda. Many critics say that ‘reforms’ like the FYFV are more about dismantling the NHS in order to have an insurance based system, rather tackling rising demand.
“The Government upholds the values and principles of the NHS: of a comprehensive service, available to all, free at the point of use and based on clinical need, not the ability to pay.”
It is already clear that only some NHS services will remain based on clinical need. The British Medical Association noted in 2012 that rationing was already beginning to put some patients’ health at risk. http://www.guardian.co.uk/society/2012/aug/31/nhs-rationing-risking-lives-doctors-leader. By 2015, there is evidence of widespread rationing (see, for example, http://www.telegraph.co.uk/news/nhs/11771294/Hearing-aids-and-vasectomies-rationed-as-NHS-pressures-bite.html ).
Promises that health care will remain free at the point of use are entirely consistent with a healthcare service based on private insurance.
Following the 2015, there have been moves, such as a debate in the Lords, or speeches by the Health Minister, towards preparing the public to accept charges for health care. https://www.opendemocracy.net/ournhs/richard-grimes/government-moves-to-consider-nhs-user-charges .
What is happening to the NHS can be seen as a larger plan to shrink state provision. The way things are going, within the next five years, Britain will have a smaller public sector than any other major developed nation. http://www.guardian.co.uk/commentisfree/2012/oct/15/graph-cameron-wants-shrink-state
These were Conservative pledges before the 2010 election. But while the public was being reassured about the future of the NHS, the Conservative Party was carrying out long-standing plans, spearheaded by Oliver Letwin and John Redwood and dating from the 1980s, to undertake the largest top-down re-organisation of the NHS since its inception. This included opening it up to private healthcare companies and shifting it towards a US-style system based on private health care insurance (see for example, http://liberalconspiracy.org/2011/06/03/revealed-the-pamphlet-underpinning-tory-plans-to-privatise-the-nhs/, plus our page on The Long Term Plan).
In 2004 Oliver Letwin was reported to say at a private meeting with representatives from the construction industry that “the NHS will not exist” within five years of a Conservative election victory. Instead the NHS would be a “funding stream handing out money to pay people where they want to go for their healthcare” (http://www.independent.co.uk/life-style/health-and-families/health-news/letwin-nhs-will-not-exist-under-tories-6168295.html).
The Coalition government brought about many of the ‘reforms’ proposed in the Letwin/Redwood plan, through its Health and Social Care Act of 2012. But by the autumn of 2014, as it was becoming clear that the NHS was becoming one of the key issues for the 2015 general election, attempts were made to distance the Prime Minister and the Chancellor from the ‘reforms’. Downing Street sources suggested that the massive restructuring of the NHS had been a mistake and that the plans drawn up by the Health Minister, Andrew Lansley, had been his and his alone: “No-one apart from Lansley had a clue what he was really embarking on, certainly not the Prime Minister.” (see The Times, October 13th 2014, pages 1 & 2.). What a tangled web we weave …. (see for example, http://www.telegraph.co.uk/health/healthnews/9095923/David-Cameron-Health-Secretary-Andrew-Lansley-has-my-full-support-over-NHS-reforms.html.)
Prior to the 2015 election there were again assurances from the Conservative party that the NHS was safe in their hands. These coincided with the introduction of the Five Year Forward View by NHS England, which aimed entirely to restructure the NHS again, this time by integrating different services into new ‘models of care’ (similar to Accountable Care Organisations in the US). Although this reorganisation is described as locally led rather than being imposed top-down, the development of new models of care will be closely monitored, if not guided, by NHS England and, arguably, bring about the gradual transformation of the NHS into an insurance-based health care system – the last stage of the Letwin/Redwood plan described above. (see also our page on the Five Year Forward View) .
“The new NHS will be better because it will be run, by and large, by our GPs, who are best placed to understand the needs of patients”.
The restructuring of the NHS has been sold to the public partly on the basis that services will be commissioned by GPs as they are best placed to know what their patients need. However, this is a misleading claim for a number of reasons:
- Commissioning health care services is a complex and specialised task that requires legal knowledge (e.g. about competition law) and understanding of the tendering process, as well as administrative and financial skills. GPs do not have the skills or time to do this. Commissioning will be handed over to support services, often run by private companies who may be linked to private health care providers.
- Only a third of GPs are actively involved in the work of CCGs (and of these, many have links with health insurance or private medical companies).
- GPs’ decisions about their patients’ needs are already being over-ruled (e.g. by Referral Management Centers) to minimize the number of patient referrals that GPs make.
- GPs will have less time to spend with patients because of the demands of clinical commissioning.
Polls now show 73% of GPs feel they have been set up to take the blame for the rationing of healthcare.
The ‘reforms’ have been acclaimed by the government as increasing patient choice. But this is not as good as it sounds:
- The proposals for the NHS tend to make no distinction between ‘choice’ and ‘shared decision-making’. Good GPs will anyway work in partnership with their patients and ensure shared decision-making about the nature or extent of patients’ care or treatment. The ‘reforms’ do little to ensure this where it is not already happening. (more…)