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National Health Service: not for sale
Perspectives
Book National Health Service: not for sale Dismantling and selling off a vital public service such as the UK’s National Health Service (NHS), valued by a public overwhelmingly opposed to its privatisation, requires fancy footwork and dirty tricks. Those who wish to pull off this feat must be willing to misrepresent the organisation in question, subject it to relentless criticism (implicitly making the case for yet another “radical reform”), and deceive the British electorate. In 2010, the Conservative-led Coalition Government stepped up to the plate. As a result, the instrument of NHS privatisation—the then Secretary of State for Health Andrew Lansley’s catastrophic Health and Social Care Act—reached the statute book in 2012 after a bumpy passage through Parliament. A year later, it got to work on its victim, although there had been a good deal of activity behind the scenes to prepare the NHS for market. The results have been predictably dire. The mother of all top-down reorganisations—proposed in a White Paper published a few weeks after the Coalition partners had promised no more top-down reorganisations— has diverted an estimated £3 billion from patient care, and consumed vast amounts of clinical and managerial time. There has been a huge increase in the number and complexity of organisations required to manage the NHS—notwithstanding Lansley’s promise that his “reforms” would result in less bureaucracy. In October, 2014, some senior Conservatives admitted that they regard this NHS reorganisation as “their biggest mistake” (an accolade for which there must be fierce competition). Prime Minister David Cameron’s reported claim that he did not understand the Health and Social Care Act he had supported so strongly www.thelancet.com Vol 385 February 21, 2015
sounds to me like an admission of criminal negligence towards the nation’s health. It is, however, more likely that he is being disingenuous. After all, aside from the damage it has caused the Health and Social Care Act is still delivering privatisation, the fundamental purpose buried in its 354 pages of deliberate obfuscation. Selling off the NHS, and distancing the UK Government from responsibility for ensuring comprehensive health care, has been a Conservative dream since it was first proposed by Geoffrey Howe some 30 years
“…perhaps the most alarming message from NHS for Sale is the subversion of due process and democracy.” ago, and has been enthusiastically endorsed by key current policy makers in the Conservative Party such as Oliver Letwin. Thanks to Lansley, this dream still has a chance of realisation. Many of the defenders of the Health and Social Care Act claim that it has nothing to do with privatisation and that privatisation is not happening. In fact, about a third of contracts awarded between April, 2013, and August, 2014, went to the private sector. After a slow start, the pace is quickening with billion pound contracts now up for grabs. We ain’t seen nothing yet. The malign effects of privatisation on the values and efficiency of the NHS, already damaged by earlier phases of marketisation under the previous Labour Government who introduced private contracting for specific purposes such as reducing waiting lists, are clearly apparent. Competitive tendering is expensive, time-consuming, and disruptive. Essential collaboration between organisations for the benefit of patients is vulnerable to legal
challenge by private providers who see it as anti-competitive. Private companies, often proving to be better at tendering than delivering services, have picked up and dropped pieces of the NHS as the bottom line dictates, with a callous disregard for the impact on patients and the wider destabilising effect. The recent return of the privately run Hinchingbrooke Hospital to the NHS is only the most high profile of a series of disruptive private sector withdrawals from contracts. The freezing of budgets and the axing of services (more broken promises) have only exacerbated the consequences. NHS for Sale: Myths, Lies and Deception is a brilliant account of the shocking story of the Health and Social Care Act: how its true purpose was concealed from the electorate (with the assistance of the media asleep on the job), how it was sold to Parliament, and its appalling consequences. Unlike the politicians they subject to forensic scrutiny, Jacky Davis, John Lister, and David Wrigley keep their promises, dissecting the myths and exposing the lies flagged up in their subtitle. The master myth justifying the Lansley reforms was that the NHS was a clinical and financial basket case and needed a radical shake-up. The NHS certainly has problems. There have been serious lapses in patient care, illustrated by the scandal at the Mid Staffordshire NHS Foundation Trust. There are major financial pressures on a health budget not able rise in parallel with increasing demand for care. Accident and emergency departments face unsustainable pressures. And some NHS and Foundation trusts are moving into deficit. However, successive Commonwealth Fund Reports in 2011 and 2014 showed the NHS to be world-beating by many important
NHS for Sale: Myths, Lies and Deception Jacky Davis, John Lister, and David Wrigley. Merlin, 2015. Pp 200. £8·95. ISBN 9780850366273
681
Mark Kauffman/Stringer/Getty Images
Perspectives
Minister of Health Aneurin Bevan on Feb 1, 1949
criteria, including access to and quality of care, and value for money. As for the £20 billion efficiency saving predicted to be needed for the NHS by 2015 by the previous NHS Chief Executive Sir David Nicholson, this was a case for reversing not extending the progressive marketisation that has tripled transaction and administrative costs over the past few decades. The mantra at the heart of the Health and Social Care Act was “patient choice”—“no decision about me, without me”. This was used to justify the introduction of greater competition from “any qualified provider”. In practice, as NHS for Sale underlines, privatisation diminishes patient choice: the privateers decide which patients to take on and which to reject. The claim that the Health and Social Care Act would put general practitioners (GPs)—closest to patients and their needs—at the heart of commissioning has proved false. Many GPs are disenfranchised and increasing clinical pressures and recent changes to their funding have made it ever more difficult to deliver 682
services to their own patients, never mind engage actively in broader commissioning processes. They feel disempowered as never before. Moreover, the promise of “increased trans parency”, with communities having a greater say in decisions about commissioning health services, has not materialised. On the contrary, local accountability has all but vanished. Commercial confidentiality seems to trump all other considerations; it prevents concerned citizens from challenging apparently perverse commissioning decisions, such as awarding contracts to providers with a poor track record. This lack of transparency raises suspicions about what is going on behind closed doors. Healthwatch, the body charged with representing the views of local people, has edentulousness designed into it; so much so that citizens, frustrated by the invisibility and impotence of these statutory bodies, have developed their own pressure groups, taking to social media and the streets to protest at being excluded from any kind of democratic deliberation over who provides what services— and over the cuts, closures, and reconfigurations that will impact on their health. The claim that the private sector provides health care more cost effectively than the public sector would be surprising if true. Multiple private providers inhibit integration of services, block the sharing of expertise and resources, and their necessary profits divert taxes from health care. The international evidence is decisive: private health care is more expensive and wasteful, often denying treatment to those who need it and selling unnecessary interventions to those who don’t. The primary aim, after all, is not to heal the sick but to shift product. While the ideologically inspired damage inflicted on the NHS in recent years is shocking, perhaps the most alarming message from
NHS for Sale is the subversion of due process and democracy. The book details eye-popping conflicts of interest—nearly 40% of GPs on Clinical Commissioning Groups have an interest in selling products they are commissioning, government advisers and the ubiquitous paid consultancies benefiting financially from their own advice, civil servants and Parliamentarians rushing from the corridors of power to lobby for the private sector, and donors to political parties being rewarded with contracts—that reveal how the health of the nation is being sacrificed to serve the interests of a venal political class. The barriers between corporate interests and political decision making have all but collapsed. Corruption, deception, mythspreading, and lying on the scale described in NHS for Sale should be headline news. Instead, the debate leading up to the election is distracted by second-order issues, such as the Labour Party leader’s use of the verb “weaponise” in relation to the NHS. The case for ensuring that the current Coalition Government must not be allowed anywhere near the NHS after the 2015 election, and for repealing the most toxic parts of the Health and Social Care Act, is set out clearly in the evidence-based indignation of this engagingly written and scrupulously researched volume. NHS for Sale also offers many persuasive suggestions for addressing the challenges of continuing to provide first-class, comprehensive health care in UK. If it has the wide readership it deserves, it may help to save the NHS from the predators and ideologues circling round it. Otherwise, we may wake up one day and find that the NHS has been stolen from us.
Raymond Tallis I edited NHS SOS (Oneworld Publications, 2013) with Jacky Davis. I am a member of the Labour Party and a member of Keep Our NHS Public and Stockport NHS Watch.
www.thelancet.com Vol 385 February 21, 2015
Book National Health Service: not for sale Dismantling and selling off a vital public service such as the UK’s National Health Service (NHS), valued by a public overwhelmingly opposed to its privatisation, requires fancy footwork and dirty tricks. Those who wish to pull off this feat must be willing to misrepresent the organisation in question, subject it to relentless criticism (implicitly making the case for yet another “radical reform”), and deceive the British electorate. In 2010, the Conservative-led Coalition Government stepped up to the plate. As a result, the instrument of NHS privatisation—the then Secretary of State for Health Andrew Lansley’s catastrophic Health and Social Care Act—reached the statute book in 2012 after a bumpy passage through Parliament. A year later, it got to work on its victim, although there had been a good deal of activity behind the scenes to prepare the NHS for market. The results have been predictably dire. The mother of all top-down reorganisations—proposed in a White Paper published a few weeks after the Coalition partners had promised no more top-down reorganisations— has diverted an estimated £3 billion from patient care, and consumed vast amounts of clinical and managerial time. There has been a huge increase in the number and complexity of organisations required to manage the NHS—notwithstanding Lansley’s promise that his “reforms” would result in less bureaucracy. In October, 2014, some senior Conservatives admitted that they regard this NHS reorganisation as “their biggest mistake” (an accolade for which there must be fierce competition). Prime Minister David Cameron’s reported claim that he did not understand the Health and Social Care Act he had supported so strongly www.thelancet.com Vol 385 February 21, 2015
sounds to me like an admission of criminal negligence towards the nation’s health. It is, however, more likely that he is being disingenuous. After all, aside from the damage it has caused the Health and Social Care Act is still delivering privatisation, the fundamental purpose buried in its 354 pages of deliberate obfuscation. Selling off the NHS, and distancing the UK Government from responsibility for ensuring comprehensive health care, has been a Conservative dream since it was first proposed by Geoffrey Howe some 30 years
“…perhaps the most alarming message from NHS for Sale is the subversion of due process and democracy.” ago, and has been enthusiastically endorsed by key current policy makers in the Conservative Party such as Oliver Letwin. Thanks to Lansley, this dream still has a chance of realisation. Many of the defenders of the Health and Social Care Act claim that it has nothing to do with privatisation and that privatisation is not happening. In fact, about a third of contracts awarded between April, 2013, and August, 2014, went to the private sector. After a slow start, the pace is quickening with billion pound contracts now up for grabs. We ain’t seen nothing yet. The malign effects of privatisation on the values and efficiency of the NHS, already damaged by earlier phases of marketisation under the previous Labour Government who introduced private contracting for specific purposes such as reducing waiting lists, are clearly apparent. Competitive tendering is expensive, time-consuming, and disruptive. Essential collaboration between organisations for the benefit of patients is vulnerable to legal
challenge by private providers who see it as anti-competitive. Private companies, often proving to be better at tendering than delivering services, have picked up and dropped pieces of the NHS as the bottom line dictates, with a callous disregard for the impact on patients and the wider destabilising effect. The recent return of the privately run Hinchingbrooke Hospital to the NHS is only the most high profile of a series of disruptive private sector withdrawals from contracts. The freezing of budgets and the axing of services (more broken promises) have only exacerbated the consequences. NHS for Sale: Myths, Lies and Deception is a brilliant account of the shocking story of the Health and Social Care Act: how its true purpose was concealed from the electorate (with the assistance of the media asleep on the job), how it was sold to Parliament, and its appalling consequences. Unlike the politicians they subject to forensic scrutiny, Jacky Davis, John Lister, and David Wrigley keep their promises, dissecting the myths and exposing the lies flagged up in their subtitle. The master myth justifying the Lansley reforms was that the NHS was a clinical and financial basket case and needed a radical shake-up. The NHS certainly has problems. There have been serious lapses in patient care, illustrated by the scandal at the Mid Staffordshire NHS Foundation Trust. There are major financial pressures on a health budget not able rise in parallel with increasing demand for care. Accident and emergency departments face unsustainable pressures. And some NHS and Foundation trusts are moving into deficit. However, successive Commonwealth Fund Reports in 2011 and 2014 showed the NHS to be world-beating by many important
NHS for Sale: Myths, Lies and Deception Jacky Davis, John Lister, and David Wrigley. Merlin, 2015. Pp 200. £8·95. ISBN 9780850366273
681
Mark Kauffman/Stringer/Getty Images
Perspectives
Minister of Health Aneurin Bevan on Feb 1, 1949
criteria, including access to and quality of care, and value for money. As for the £20 billion efficiency saving predicted to be needed for the NHS by 2015 by the previous NHS Chief Executive Sir David Nicholson, this was a case for reversing not extending the progressive marketisation that has tripled transaction and administrative costs over the past few decades. The mantra at the heart of the Health and Social Care Act was “patient choice”—“no decision about me, without me”. This was used to justify the introduction of greater competition from “any qualified provider”. In practice, as NHS for Sale underlines, privatisation diminishes patient choice: the privateers decide which patients to take on and which to reject. The claim that the Health and Social Care Act would put general practitioners (GPs)—closest to patients and their needs—at the heart of commissioning has proved false. Many GPs are disenfranchised and increasing clinical pressures and recent changes to their funding have made it ever more difficult to deliver 682
services to their own patients, never mind engage actively in broader commissioning processes. They feel disempowered as never before. Moreover, the promise of “increased trans parency”, with communities having a greater say in decisions about commissioning health services, has not materialised. On the contrary, local accountability has all but vanished. Commercial confidentiality seems to trump all other considerations; it prevents concerned citizens from challenging apparently perverse commissioning decisions, such as awarding contracts to providers with a poor track record. This lack of transparency raises suspicions about what is going on behind closed doors. Healthwatch, the body charged with representing the views of local people, has edentulousness designed into it; so much so that citizens, frustrated by the invisibility and impotence of these statutory bodies, have developed their own pressure groups, taking to social media and the streets to protest at being excluded from any kind of democratic deliberation over who provides what services— and over the cuts, closures, and reconfigurations that will impact on their health. The claim that the private sector provides health care more cost effectively than the public sector would be surprising if true. Multiple private providers inhibit integration of services, block the sharing of expertise and resources, and their necessary profits divert taxes from health care. The international evidence is decisive: private health care is more expensive and wasteful, often denying treatment to those who need it and selling unnecessary interventions to those who don’t. The primary aim, after all, is not to heal the sick but to shift product. While the ideologically inspired damage inflicted on the NHS in recent years is shocking, perhaps the most alarming message from
NHS for Sale is the subversion of due process and democracy. The book details eye-popping conflicts of interest—nearly 40% of GPs on Clinical Commissioning Groups have an interest in selling products they are commissioning, government advisers and the ubiquitous paid consultancies benefiting financially from their own advice, civil servants and Parliamentarians rushing from the corridors of power to lobby for the private sector, and donors to political parties being rewarded with contracts—that reveal how the health of the nation is being sacrificed to serve the interests of a venal political class. The barriers between corporate interests and political decision making have all but collapsed. Corruption, deception, mythspreading, and lying on the scale described in NHS for Sale should be headline news. Instead, the debate leading up to the election is distracted by second-order issues, such as the Labour Party leader’s use of the verb “weaponise” in relation to the NHS. The case for ensuring that the current Coalition Government must not be allowed anywhere near the NHS after the 2015 election, and for repealing the most toxic parts of the Health and Social Care Act, is set out clearly in the evidence-based indignation of this engagingly written and scrupulously researched volume. NHS for Sale also offers many persuasive suggestions for addressing the challenges of continuing to provide first-class, comprehensive health care in UK. If it has the wide readership it deserves, it may help to save the NHS from the predators and ideologues circling round it. Otherwise, we may wake up one day and find that the NHS has been stolen from us.
Raymond Tallis I edited NHS SOS (Oneworld Publications, 2013) with Jacky Davis. I am a member of the Labour Party and a member of Keep Our NHS Public and Stockport NHS Watch.
www.thelancet.com Vol 385 February 21, 2015