Much of the anger about private influence in the NHS has focused on the provision of care. An increase in competition, a reduction in cooperation, the possibility of “Cherry Picking” and a profit motive perverting the provision of high quality care are understandable and real concerns. However, a far bigger threat is the increasing privatisation of the commissioning structure of the NHS.
High quality commissioning is “an absolute” in having an efficient health service. While not perfect, it was widely recognised that the SHA/PCT structure of commissioning, that Labour built, was just about as good as it gets. Lansley’s restructuring into Clinical Commissioning Groups and NHS commissioning board has put commissioning back many years and left the door wide open to private involvement.
The shift of responsibility to professionals that are, understandably, not willing or prepared to commission health care has meant that, as of January this year, over 40% of new CCGs have contracted private sector support for their commissioning roles. The prevalence of these private “Commissioning Support Organisations”, which the government has strongly indicated should be private organisations rather than NHS, will increase considerably as CCG setup accelerates this year. In a number of situations private companies are jockeying for, and achieving, the position of both commissioner and provider of health care in the same geographic area; essentially paying themselves, with taxpayers money, to provide health care. And to top it off, 50% of CCG members have existing financial interests in private providers.
With this privatisation of the commissioning structure of the NHS we are seeing the democratic accountability and control of healthcare slowly fade. The NHS is being put at arm’s length of an elected government. Private companies will increasingly control the availability of health care in England. Little or no indication has been given by the government about how a strong accountability (which differs from oversight) structure will be put in place and only the weakest of market mechanisms exist by which commissioning companies will have to respond to the wishes of the public.
This accountability is so important in commissioning for the simple reason that commissioning is different to buying. When commissioning it is possible to design the service which is being purchased; when buying you take or leave what is on offer. For commissioning to be excellent, it has to be accountable. If commissioners are accountable to the public, services are designed that are responsive to the needs of patients. If commissioners are not accountable, then generic “minimal requirement” services are normally purchased. Accountability ensures that money is spent and that money is spent wisely.
In Lansley’s NHS, the commissioning structure is the only way we can maintain democratic accountability of health care, in the face of the privatisation of provision. NHS led commissioning structures, with economies of scale and experienced managers, can help control the influence of the “profit motive” and ensure private provision responds to the public’s needs, through negotiating robust contracts. It is hard to imagine private commissioning companies, operating under the financial pressure of the coming years, being able, or even wanting to achieve this.
I am not suggesting that PCT’s had reached the pinnacle of accountability, they hadn’t. There was still work to be done. However, a clear structure of accountability was in place. Lansley is now assuming that greater locality of commissioning will automatically bring accountability. For any number of reasons this is not the case; primary among these is the influx of private companies, who have legal obligations to shareholders and not the public.
I have been castigated, more than once, by readers of this site for suggesting that private provision may have even a limited role to play in our health service. I note this to make the point that I am not someone who responds with a Pavlovian rage, or sweeping statements, to hearing “private” and “NHS” in the same sentence. My ties are to a clinically excellent, affordable and well delivered health service, which responds to the needs of the public. But let’s be clear, the privatisation of the NHS commissioning structure threatens all of these goals. Commissioning has to remain democratically accountable and this means remaining publically controlled.
A pledge at the forefront of any Labour health manifesto should be to exclude any private influence from NHS commissioning.