Andy Burnham calls for debate on NHS reforms – full speech

By Mark Ferguson / @markfergusonuk

Andy Burnham has given a major speech today in Liverpool on coalition reforms to the NHS, accusing the the government of attacking the N in NHS, and setting out his priorities for the health service.

You can read the full text of the speech below:

—

“I wanted this to be an open event because in my view nothing matters more to people in this country than the NHS – it belongs to all of us. We are on the brink of reforms that will fundamentally alter its character – and it’s time to raise an informed and inclusive debate about them.

I have spoken to many NHS staff in all parts of the country about what the government’s reform plans mean.

The threat is not theoretical but real. The very fabric of today’s successful NHS is being unpicked before our eyes. Primary Care Trusts are being dismantled without any real detail on what will succeed them, or evidence that it will work.

Then, from nowhere at the weekend, we hear that NHS Direct – a service that saves almost £100m a year – is to go without a proven alternative.

I have said that this white paper represents the biggest threat to the NHS in its 62-year history, and the purpose of today is to set out a detailed critique to substantiate this claim. I will then go on to describe my own vision for the NHS in the next decade.

I want this critique to help develop an informed debate. Such is the importance of the NHS – and the ill-conceived nature of these reforms – that I believe it will soon dominate the political debate in this country.

That is because, as I’ll explain today, there is no democratic mandate for these reforms. So, alongside the debate in parliament, we need to see NHS staff and patients given the chance to debate these proposals with MPs in villages, towns and cities up and down the country over the autumn and winter.

So, to kick-off this national debate, let me take you through five reasons why I believe these changes are so dangerous.

First reason.

They are the wrong reforms at the wrong time.

The next three years will present the NHS with a huge financial challenge. It is the worst time imaginable to initiate the biggest-ever structural reorganisation of the NHS.

Right now, the NHS needs organisational stability so all efforts can be focused on efficiency savings. By combining two major challenges – and taking attention away from finance – there is a real risk that the NHS will descend into chaos.

By 2014, the coalition expect the NHS to have delivered £20bn efficiency savings without affecting the front line. They have made this impossible by introducing a huge, expensive reorganisation at the same time.

Already they stand accused of using a ‘sledgehammer rather than a scalpel’ to find savings.

Keiran Walshe of Manchester Business School says the transitional costs of reorganisations are huge and the intended savings rarely realised. The process is a distraction from delivering care and ‘saps morale’. He says the reforms could cost up to £3billion – a scandalous use of money when every single penny should be directed to patient care.

James Gubb, from right-wing think-tank Civitas agrees that the costs will be considerable and the reforms “could set the NHS back between one and three years” which he calls “ruinous” for the goal of £20bn efficiency savings.

Even Sir David Nicholson agrees that there is a ‘significant risk of a loss of focus on quality’. As NHS Chief Executive, he has asked the NHS to set aside £1.7bn to fund these reforms.

The coalition agreement appeared to acknowledge the overriding need for stability with a promise of ‘no further top-down reorganisations’. There has still been no explanation of why the government’s thinking changed and the coalition agreement was torn up in the biggest and quickest U-turn in British political history.

Second reason.

It’s a bad deal for patients

Removing the national 18-week maximum wait takes power off the patient and hands it back to the system. As financial pressure builds, it means patients will begin to pay the price and waiting times will rise.

It took blood, sweat and tears to bring those NHS waiting lists down but all that progress is now at risk.

Long waits were the hallmark of the last Tory government. They set a target that people should wait no longer than 18 months, and missed it. Labour set a target that people should wait no longer than 18 weeks, and smashed it.

But the removal of the 18-week standard needs to be considered alongside two other proposals from the white paper – the abolition of the private patient cap and no bail-outs for NHS hospitals.

Hospitals are free to dedicate more theatre time to private patients and indeed have an incentive to do so given the market-based financial regime that is on the way. With no national NHS waiting times and no cap on the amount trusts can earn from private patients, hospitals will manage pressure by making NHS patients wait longer.

And so we face the spectre of seeing once again in our NHS that old choice for patients – wait longer or pay to go private.

Private sector firms know what it means. The NHS Partners Network said “Waiting times will go up and if people want a procedure they have a choice: they can wait or they can look to pay.”

The health secretary wants an NHS that listens to GPs. Well we hope he will listen to them too, as two-thirds of GPs think waits will rise with the abolition of the 18-week target.

The Nuffield Trust agrees, and has called for waiting standards to be retained as firm targets.

The Health Service Journal expects a ‘highly visible deterioration in services’ as a result of scrapping targets.

Longer waits matter. They matter because they affect clinical outcomes, but they also matter because they affect public confidence in the service. The NHS belongs to us all and we should know what we have the right to expect when we call upon its services.

Third reason.

A postcode lottery writ large

The creation of hundreds of new, untested GP groups means variable service standards, access and quality depending on where you live. It is an attack on the N in NHS.

It is not just traditional enemies who are highlighting the postcode lottery threat.

The Tory think tank the Bow Group identified the risk that ‘with an increased number of commissioning bodies, there is a greater likelihood of different approaches to the prioritisation of treatments and funding decisions.’

They go on to say that this is likely to result in a postcode lottery. For all the coalition’s rhetoric about localism, they know as well as we do that the public hate postcode lotteries.

They see them as unfair, because they are unfair. Those people who cannot afford to move to another area are left with substandard care. National standards in the NHS empower the patient and are a guarantee of a minimum standards for all.

‘Lobby your GP’, the government cries.

But people don’t want to have to fight for their healthcare, and GPs don’t want it either. Many families don’t have the means to move is they are not happy with their local service.

The role of GP as champion of their patient is compromised by their role as budget-holder. It is also the case that the GP will be both a provider and commissioner, placing a major conflict of interest at the heart of the NHS.

Fourth reason.

Fragmentation and privitisation – forcing Trusts to leave the public sector will create an unstable free market and change the character of our hospitals.

The hand-over of the budget represents the privitisation of the commissioning function in the NHS and a green light for private consultants and contractors.

I have great admiration for British general practice and GPs and don’t doubt the commitment of the vast majority to the NHS. But there is a large irony in the fact that the very group that refused to be a part of the NHS at the very outset, and has remained outside ever since, has now been handed practically the entire budget to spend.

I wonder what Nye Bevan would have made of it.

Since it began, the NHS has operated within a framework of public control, so that essential services are protected.

These reforms blow that careful balance apart, with Foundation Trusts re-classified so they are no longer on the government’s balance sheet.

This moves hospitals out of the public sector, meaning there would be no such thing as an ‘NHS hospital’, just hospitals that provide care to NHS patients, alongside private patients, if they choose. Competition law would reign supreme, overruling the BMA’s exhortations to GPs to make the NHS the provider of choice.

There’s no opt-out for providers, so if they’re not ready or willing to become stand-alone social enterprises, they will be forced to close, merge or be taken over by other providers.

At the core of the social enterprise movement is the entrepreneurial impulse of the people that set up these organisations.

A dictat from Whitehall forcing NHS staff to become social enterprises and compete on a level-playing field with the private sector flies in the face of the that model

The checks and balances that Labour placed in the system will be wiped away. There will be no limit on how much a trust can borrow. If a trust gets into financial difficulty it will not be helped, meaning that the state-owned assets currently in the NHS could be at risk.

The instability these reforms create means that healthcare providers will need to pay a fee to the economic regulator to insure themselves against the risk of going bust.

They don’t pay this now, because the Treasury provides financial guarantees. The effect of these reforms is to alter the character and behaviour of our hospitals.

Funding will be diverted from patient care to pay for a free market.

On the commissioning side, the government’s proposals allow for the wholesale privatisation of the commissioning function.

Most GPs do not have the skills, experience or desire to assess whole population healthcare needs, manage a market, negotiate contracts and monitor performance.

It is unsurprising that GPs would look to the private sector for help, not least to help them underwrite the considerable financial risk that the government is ordering them to take on.

These organisations frequently provide management and commissioning support but also healthcare services. There is therefore a conflict of interest between GPs and their private sector partners acting as both providers and commissioners.

I believe there is a real risk that GPs are pressured into referring patients to those services provided by their private sector partners.

Fifth reason.

No public accountability – the dismantling of PCTs and allocations set by an independent board combine to create a real lack of public accountability. It is not at all clear what ability patient groups will have to challenge commissioning decisions.

Local authorities have an oversight role and must set up groups to capture the views of local people. But as councils will have no power over commissioners of care, or care providers, it would seem to me an empty gesture.

By stripping away performance management in the system, the ability for patients to escalate concerns has gone. We’re told that the NHS Board won’t overturn local decisions.

Part of local accountability is that public services have a duty to provide for people who don’t have a voice. Some people can be less visible to services – such as carers, people with mental health problems, homeless people or the travelling community.

PCTs work with Local authorities to identify these people and meet their needs. It is not clear how GPs will be made accountable for whole-population needs.

The public accountability that is one of the safeguards in the system is being wiped away. Patients are expected to vote with their feet, if they can, and the rest will be left to the market.

The fears of the parents of a young boy with Duchenne Muscular Dystrophy, appearing on Newsnight last week, went to the heart of what the threat really means. What reassurance can the coalition give them that their new, untested GP consortia will get their son the support he needs?

Many people with mental health problems are also fearful. Rethink found that two-thirds of GPs are not confident about commissioning mental health services.

On the same Newsnight package, a GP said:

“There will always be winners and losers… There are conditions that society sees as greater priorities than others, and I don’t have the answer to that yet.”

People with long term, complex conditions need an answer, now.

We didn’t create the NHS for there to be winners and losers. We created it to provide universal healthcare to our population, based on need, without regard to the condition that created that need.

So – five reasons to fear these reforms.

Five reasons to defend our NHS from the threat it faces.

The Tories posed as friends of the NHS in the run-up to the election. There was no mention in the campaign of this bombshell they were about to drop on it.

So it’s not surprising that, after just 100 days in government, the coalition is facing legal challenge over its NHS reforms – which neither coalition partner told voters about at the election and which was explicitly ruled out in their own coalition agreement.

Disquiet is rising over these reforms, with voices on all sides beginning to warn that the risk of failure is too large.

The BMA are urging GPs not to take any action until national contract negotiations have taken place. They have called the proposals a ‘major threat’ and have spoken out against private sector involvement.

The Patients Association said the reforms were a ‘massive reorganisation’ that could lead to instability.

The National Association for Primary Care admitted last week that it seems more people object to the Government’s reforms than support them.

The government will accuse us of a knee-jerk opposition to any change. They will seek to cast Labour as the defenders of bureaucracy.

What they don’t like to hear is that the Commonwealth Fund recently passed it’s verdict on Labour’s NHS – the most efficient health service in the world and second overall on quality.

Let me be clear. I am not arguing for no change. As health secretary, I was careful not to overclaim for the NHS.

It has gone from a service on its knees to one delivering good care to the vast majority of patients with universal guaranteed standards for all.

But as I acknowledged as health secretary, there were areas where care fell well below acceptable levels. Mid-Staffordshire is the tragic example we will always remember.

So there is further to go. The NHS, like all our public services, must evolve. We all know the challenges: demography, advancements in technology, and the need for increased productivity.

We need to move from a welfare state to a wellbeing state. A paradigm shift – away from ‘diagnose and treat’ towards ‘predict and prevent’. The NHS promoting good health and preventing ill health, instead of a treatment-only service.

Prevention as the aim of all public services, with physical activity as core NHS business.

Recognition of the importance of mental health alongside physical health, and an understanding of how one plays into the other.

Integrated services around individuals delivering person-centred support, with attention paid to their life circumstances especially if they have a carer.

My vision is built on what I see happening in the NHS already. This morning I visited the new Whiston Hospital and saw preventative, person-centred services.

The wonderful Hospital at Home scheme, helping sick children stay out of hospital as much as possible. These interventions provide better care for people, and are also more productive.

Five principles underpin my vision of the positive NHS that this country deserves:

1. Universal – providing national guarantees on quality and access to services
2. Personal – providing healthcare the way patients want it
3. Preventative – helping the public and patients stay well
4. Integrated – delivering care alongside Local Authorities
5. Productive – delivering the best value for money

A person-centred, preventative, integrated NHS is a more productive NHS.

Given the choice, people prefer care closer to home rather than more expensive hospital care. Preventative services reduce demand, freeing up resources to provide excellent care when people do fall ill. And an integrated NHS would allow savings by sharing back-room functions.

I made the argument as Health Secretary for tough decisions to be taken in the NHS, to move services closer to the patient and build a sustainable health service. This was always a difficult debate but we must not shy away from it.

In the wellbeing state, the National Health Service works alongside the National Care Service.

I believe that healthcare and social care, in the future, should be delivered free at the point of use.”