More than a logo?

By Richard Bourne – Socialist Health Association

In the 1997 election Labour campaigned on saving the NHS which according to the Kings Fund it achieved. By 2010 the NHS was hardly an election issue at all, huge investment having brought funding and outcomes up to the best levels internationally.

Soon after the election the coalition ignored earlier promises and launched the biggest reorganisation of the NHS in its history, which looks like provoking a major political battle. The responses to the white paper proposals varied from “this is the end of the NHS” through “this is just an acceleration of what was already proposed under Labour” (Blair/Milburn anyway), to “this is all too little and too slow”. In general most heavyweight responses were sympathetic to the aims but highly critical of the proposals for achieving them; arguing that reorganisation on the scale proposed, especially at a time of financial strictures, poses very large risks to the system and more importantly to the patients.

But, even if the changes go ahead it is unlikely patients will notice any difference for years; most will get an ambulance, pitch up at A&E, see their GP and visit their local hospital or clinic in much the same way. Charges are not being introduced wholesale and funding remains from general taxation.

However the risks are that patients may wait a bit longer, and waits will stop getting shorter, but nothing like the waits of 10 or 15 years ago. There will be a slowing down of the remorseless progress made in improving health outcomes. Some support groups and a lot of the support infrastructure will end through lack of funding (unless the Big Society really takes off). The disconnections between different tribes delivering care will continue and patients will fall through the gaps. Inequalities will increase, NHS staff (if there are any left employed by the NHS) will be fewer and even harder pressed. A few services will close down, a few clinics and hospitals may have to be shut and fewer beds available – but all that is consistent with what has been happening for years.

The intention of the proposals is to transform the NHS from a national service into a market system with price driven competition. Patients will be free to choose which GP they go to and where they get their treatment; any organisation can offer the treatment as long as they meet some national (NHS) standards and charge the NHS list price, or less.

Care will be provided by competing autonomous organisations which can set their own staff terms and conditions; treat as many non-NHS patients as they wish; and raise their own capital. And they can go bust and fail. In no real sense will they be NHS organisations. They may be huge international private companies or three person social enterprises. The sign outside your local hospital may include the blue NHS logo but what that means will be less than clear.

Nobody will actually manage these organisations; that will just be left to the market and a couple of giant quangos ensuring unhindered competition. Somehow all this will happen without any wider area coordination, any planning or even any intervention to ensure continuity of vital life saving services. The magic of the market is enough .

At a local level there will be “commissioners” who are groups of GPs who will make sure the system works. They will assess needs, design care pathways, develop the “market” and award appropriate “contracts” although the huge range of conflicts of interest this opens up will have to be sorted out first. They will make decisions about local priorities and what services and facilities are necessary and what schemes are invested in, although in the end choice by patients and competition between the providers will outrank any local decisions and plans. Many of us believe the NHS is more than just a logo or a system. We believe it embodies something fundamental about social solidarity, about how we share some risks amongst everyone in our society, about how we should care for people who need help and how we should sometimes put cooperation and collaboration above profits and competition. If the NHS is inefficient (and it is) then at least some of that is the price for it being free of corruption, huge salaries and obscene bonuses; free from the occasional but hugely damaging scandals and collapses endemic in private markets; free from the suspicion that those treating you may be motivated by anything other than the desire to see you well again. Do you want to be asked which A&E department you choose as they load you on the stretcher?

We believe that health care is part of our whole drive for well being and that public health (looking after the population), social care, and mental health should all be bound into the rest of our public services, not fragmented and disconnected. Partnership and cooperation rather than competition.

Of course the NHS should continue to use many suppliers and providers of all kinds but they are contracted to the NHS not running it.

But do we really want to be like the US which has the most developed private provider market system alongside millions of people excluded from care, the highest administration costs of any system and some of the worst health outcomes in the world?