Wednesday, January 19, 2011

Unhealthy NHS reform

The UK coalition government today introduced its Health and Social Care Bill 2010-11 to parliament for first reading. In its short life so far this Bill has, to quote Malcolm Tucker, been about as popular as a turd on a trampoline. The cross party Health Select Committee described it as inefficient, risky and a hand-grenade thrown into the system, and newspapers reported mass public concern including a petition that's gained 10,000 signatories already.

Officially, the Bill will let GPs, with their detailed knowledge of local patient needs, decide how resources are spent instead of primary care trusts. So far so sensible, but something sinister lurks alongside, which the government sweetly calls “liberating the provision of NHS services”.

In translation, this means allowing private companies to replace NHS providers if they can beat them in competition. Care will still be free, but the providers may answer to shareholders not voters.

This is where the problem lies: universal healthcare and the pursuit of profits often pull in different directions. Yet despite this obvious fact the Bill puts private provision at its centre. Private healthcare outside the NHS is one thing, but inside the NHS it makes for trouble:

1. Private companies need to make a profit, which adds to costs. With no profits (or insurance companies and lower transaction costs) to fund, the NHS for all its failings is one of the cheapest health providers in the developed world. The UK spends only 8% of GDP on health to cover its entire population, compared with 15% in the USA to cover only a third of its population. It's hard to see how adding a margin for NHS providers will make the budget go further.

2. Competition inside the NHS will likely lead to hospital closures, causing either concentration or capacity reduction. This means either fewer people will be treated or facilities will become bigger and less local. Private providers will encourage this to capture more business, undermining the NHS objective of universal local healthcare provision.

3. Health facilities, like schools, are valuable community resources. If they underperform, they should be improved, not driven out of business.

4. Private companies, which lack a public service obligation, will be free to cherry pick higher margin services and the best staff, hollowing out the NHS to leave a two-tier national health system and diminish the NHS's prestige.

5. Centres of excellence, such as teaching hospitals, could pass from public to private ownership, severely distorting research priorities. The public health agenda will go the way of big-pharma.

6. Health facilities that fall into private hands could become prey for one-off financial engineering. I can already imagine the private equity sale-and-leasebacks and dubious outsourcing contracts (for a description of how this has already played out in the US, including shocking and life-threatening cuts in service, see "Doctoring Customer Servicer", chapter three of Josh Kosman's "Buyout of America").

7. Private health provision will undermine the NHS’s vocational ethos, which provides job security to staff, a rational training and career path and a strong culture of public service. The NHS has taken generations to build and is admired in the international medical world; we should not be so casual with its culture.

The GP reform also faces practical difficulties:

1. How will local GPs decide on strategic national matters, such as preparing for epidemics or prioritising expensive treatments for rare conditions?

2. Administrative savings could be modest if GPs have to employ managers to help with their new burden.

3. GPs will spend less time in the surgery and more in budget meetings.

4. GPs have already complained that budgets will create conflicts with clinical judgement that could undermine patient/doctor trust.

Finally, the whole Bill lacks political legitimacy as it was not clearly flagged in the Conservative or Lib-Dem election campaigns.

The Lib-Dem manifesto is pretty clear, pledging on page 43 to "end the current bias in commissioning towards private providers." That sounds like the opposite of the current Bill, perhaps we can put that U-turn down to coalition politics.

The lack of Conservative mandate is more worrying. Hidden in the 17th point at the very bottom of the Conservative manifesto healthcare webpage is a reference to "greater involvement of independent and voluntary providers". There is no mention of "private providers", "profit" or "abolition of primary care trusts" and nothing to suggest such an extreme subversion of NHS principles as today's Bill. The scale of philosophical change implied by private provisioning makes this sneakiness particularly bad.

I think it's fair to say that the electorate has been hoodwinked.

The leg-up for the private medical industry is particularly suspicious given the £750k campaign contributions it reportedly made to the Conservatives before the last election.

There must be other ways to increase GP influence without sacrificing national health to profit-maximisation. As the Health Select Committee said in its response to the reform, we should have had a debate about the proposal and its alternatives before starting the legislative process.

Today is only the first reading, there is still time to write to your MP...

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