Image: Health Secretary Jeremy Hunt
Don’t worry about the fact that 82% of GPs are planning to leave or cut their hours in the next five years. Don’t worry that junior doctors aren’t any happier. And don’t worry that every week reveals another NHS hospital deeply in the red – even ones we thought were ok.
Don’t worry about any of that, because Jeremy Hunt has a plan.
It’s the NHS’s own plan, he repeats in every media interview. It’s the plan it would be a ‘disaster’ to deviate from, he told us before the election.
But what is this plan?
We’ll get to that in a minute.
First, let’s look at what we’re being told it’s not.
It’s not like that toxic Andrew Lansley stuff, the pro-competition 2012 Health and Social Care Act, the “reorganisation so big you can see it from outer space”. No, that was Cameron and Osborne’s “worst mistake”, they’ve let it be known. It wasn’t really their fault, of course - they didn’t have “a clue” what the then Health Secretary was up to.
They were so cross with him, they made him a Lord. And he was such an incompetent fool, he’s just landed a job at private equity firm, Bain, advising on healthcare privatisation.
But let’s not worry about that. Lansley’s 2012 Act is “being ignored” anyway, pro-market voices like the Health Services Journal tell us. Forget competition, forget the idea of external takeovers and internal dog-eat-dog competition between fragmented NHS 'Trusts' and cash-strapped local 'commissioners'. Oh no – under current Health Secretary Jeremy Hunt and NHS boss Simon Stevens’ plan, it’s all about collaboration now. Even KPMG (who’ve just poached another former Health Secretary, Steven Dorrell) say so.
So what is this plan? And, er, collaboration with whom?
Has Simon Stevens – long-time advisor to Tony Blair, and former Vice President of US health mega-corporation United Health – really sent the private health industry packing? And – after a few brand-damaging failures - have private health firms really scuttled away defeated from the £120bn “unopened oyster” of the NHS budget, deciding the NHS would be ‘shown some mercy’ after all?
It would be nice to think so. The more naïve sections of the liberal media have certainly bought that idea. When Simon Stevens launched his “Five Year Plan” last year, Andrew Rawnsley in the Observer said he had “only one fundamental objection” to the “generally excellent” plan - that it had the wrong picture on the cover. Polly Toynbee in the Guardian told us Stevens' plan was great because “the word competition doesn’t appear once in his 37 page document”. Shadow Health Secretary Andy Burnham appeared to sort of welcome the Stevens plan, then to sort of welcome it not quite so much.
Aside from this site, one of the few mainstream commentators to nail what the Stevens’ plan was really about was Fraser Nelson, in the Telegraph. “Like the best revolutions, it came carefully disguised,” Nelson observes. Yes, “the c-word [competition] didn’t appear once” but (like Nelson himself) Stevens still “firmly believes” in the competition/choice agenda – he's just experienced enough to know that “the secret of successful radical reform is not to announce it with any fanfare.”
Nelson nails it when he says: “Stevens' Grand Plan is to have no more Grand Plans but, instead, lots of smaller plans.”
So what are these smaller plans – and what do they mean for the future of the NHS?
Whilst even Jeremy Hunt and his regulator Monitor have tacitly admitted that standalone, competing Foundation Trusts aren’t working, Hunt and Stevens see more privatisation, not less, as the answer.
‘Collaboration’ turns out to mean hospital mergers into ‘chains’ – a theme developed in the Stevens report. The man tasked to develop the ‘chains’ plan, Sir David Dalton, has suggested it could lead to more private takeovers. Junior health minister Lord Prior wants private takeovers of hospital chains, too – and he also thinks they should close lots of beds.
As Circle have found in the UK with their disastrous Hinchingbrooke
foray, at the moment it's hard to make a profit from competing to provide full
service local hospitals.
As United Health, Kaiser and others have found in the U.S. - profit opportunities are much bigger if you integrate both the purchasing and provision of healthcare under private control or influence, enabling you to ration or deny more expensive healthcare interventions.
And it’s much easier to do that if you use your control or influence to reorganise provision. To shift health services away from full service local hospitals staffed by well-trained, fairly-paid workers, towards a chain of disparate 'community-based' clinics and far-flung specialist centres, with high-level expertise becoming harder to access. Of course you have to claim all the while that this is all about integration, prevention, empowerment, localism, personalisation, specialisation, reducing ‘variation’, and ‘care closer to home’.
Stevens is pushing this approach through a range of supposedly 'integrated' new ‘smaller plans’. Like the new multi-billion pound lead provider framework to ‘help’ with purchasing healthcare (which United Health subsidiary Optum has won a sizeable chunk of). And a 'prime provider' framework to ‘integrate’ purchasing and providing (which both Circle and Virgin have won contracts worth billions for already). Not to mention huge 'devolution' projects - and the array of 'local' NHS 'Vanguard' projects, which Stevens explicitly suggests could be modelled on US firm Kaiser Permanante’s ‘Accountable Care Organisations’ or similar Spanish companies. The tech-heavy projects are full of private sector opportunities and partnerships - particularly outside of unprofitable acute care. Meanwhile, tariff cuts leave the sword of Damocles dangling over many local full service hospitals.
Profit opportunities also expand if firms set their own easily-gamed 'outcome based' success measurements. Out go what Stevens calls ‘mechanistic’ measurements (like the requirement to have enough nurses, properly trained healthcare workers, and hospital beds).
Since the general election, Stevens and Hunt have been busy tearing up such staffing requirements.
And bringing in easily gamed ‘outcome’ measures in the new style contracts.
Profit opportunities also expand if co-payments (ie, patient charges) are permitted. The right are getting more confident in calling for such charges. Lord Prior has tried to launch an inquiry to consider it – and the government has still not clearly disavowed such an inquiry. The growing number of exponents of charges and co-payments are usually keen to stress it would only be for freshly defined 'non-core' services which, if you look closely, turn out to mean things like a bed to recover in after your op (£75 a night please!).
And there are many other attempts underway to undermine the
comprehensive, universal, publicly funded core values of the NHS, by bringing
the ‘undeserving’ narrative from benefits, into the NHS. An early sign is the
attempt to refuse
people care if they smoke or are obese, for example (cavalier to the fact
that it is poorer people who will be disproportionately hit by such clinically
uninformed decisions). Whilst Devon’s attempt to do this failed, experts saw it
as a sign of things to come.
Stevens has just given all of this a big boost by pushing integrated health and social care budgets (and indeed integrated benefits budgets in some devolved areas, like Cornwall). Integrated care may be nice in theory, perhaps, but integrating the budgets is a pretty terrifying prospect, given a climate of ‘austerity’ where social care users already can, and have to, top-up or co-pay for services (and benefits are already heavily conditional).
And integrated 'personal budgets' - which Stevens has been pushing since day one in the job - are now being rolled out to millions. No-one has yet managed to explain how these are any different from the old Thatcherite health voucher plan (which would basically finish the job of destroying the NHS).
Lastly, as a big bonus, once firms nabbing all these contracts have
their hands on the patient data needed to commission healthcare (or obtained by delivering it ‘digitally’),
they can also make a packet selling our information to data, insurance and
pharmaceutical companies – or worse.
Of course this entire bureaucratic market nightmare costs a fortune to administer, though the scale of the fortune is a closely guarded secret. The Health Select Committee critcised this secrecy and extra expense in 2010 (referring to earlier data – and we’ve had two or three more tranches of ‘marketisation’ since then).
So if that’s the Stevens plan, what’s our plan B to get out of this mess?
First, the NHS urgently needs a cash injection to get it through this current
manufactured crisis (with the DoH handing billions back to the Treasury in
'underspends' in recent years - 'doh!' indeed!).
Healthcare needs are not a bottomless pit, as the neoliberal ideologues claim - but the demands of health, insurance, pharmaceutical, data, consultancy and tech companies for profit streams, may well be.
Ultimately, all this destruction is possible, not because of Stevens himself, but because the Coalition government finally removed the duty to secure comprehensive healthcare which was offered to the nation in 1948 and persisted, just about, til 2012. We need to restore that duty.
And we need to recognise that hospitals have been brought low by a combination of PFI debt and the dog eat dog, beggar my neighbour nightmare of even the ‘internal’ market, let alone the external one. We need to get rid of that market – as Scotland has done.
The NHS Bill – sponsored by Caroline Lucas, signed by Jeremy Corbyn when he was a backbencher, and due for its second reading in March 2016 - is a serious attempt to do both.
The market, internal or external, disguised as ‘collaboration’ or not, is not an effective way to allocate healthcare – we’ve known that since the pioneering work of Nobel prize winner Kenneth Arrow in the 1960s. It forces hospitals to hammer down staff costs and offload unprofitable patients, and creates impossible choices between the bottom line and patient safety.
It’s only ideology and vested interests that would seek to persuade us that the answer is more of the same.
And if anyone – Tory, Labour, or ‘non-political’ – says they support the NHS, we need to ask – do you mean an NHS that is comprehensive, universal, publicly funded, high quality, timely and ethical?
If not, they are not defending the NHS as the public understand and love it. And that’s what we need to fight for.
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