Image: Propaganda poster for Stalin's '5 Year Plans'
There’s no “magic money
tree” - except when you’re signing off HS3 on a ‘nod and a wink’ for £7 billion, or interventions in Iraq and Afghanistan for £30 billion.
In October Simon Stevens set out his “five year plan”for the NHS. As a piece of marketing,is nice and succinct. It sets out a stall for the role of the NHS in a global economy. As a piece of strategy, it is dreadful. It’s dreadful whether you take the view that health provision entirely market-driven - or you view it through a more sophisticated clinical prism.
“Five year plans”. The phrase is redolent of Stalinist Russia. Nazi Germany preferred ‘four year plans’ as a
strategy for war readiness.
Stevens' “Five Year Forward View”, published last week by NHS England, is a collaboration between the six main organisations now running the NHS - Monitor, Health Education England, the NHS Trust Development Authority, Public Health England, the Care Quality Commission and NHS England itself.
The “5 year Forward View” reads like a wish-list for further privatisation of the NHS.
It may ‘pack a punch‘ for the BBC - which has throttled mainstream media discussion of NHS privatisation.
But talk of ‘accountable care organisations’, as
developed in Spain and the United States, and the emphasis on preventive health
packages so keenly sold by multinational corporates, are paradigmatic of a privatisation
The document is a naked shill, intended to carry on the ‘case for change’ made exhaustively by think tanks such as the King’s Fund. Such organisations were instrumental in giving the catastrophic policy of market competition in the National Health Service some legs in the first place.
Take, for example, the seemingly-modest proposal of “integrated care commissioning”. In the full glare of sunlight, the policy of personal budgets looks incredibly anaemic.
A big unanswered question is how a universal
health system is going to be successfully merged with a means-tested social
care system. NHS England tried, unsuccessfully to head this issue off at the
pass as far back as 2012.
Personal health budgets, which Simon Stevens is busy quietly rolling out, are the perfect vehicle for merging the two systems in a way that introduces 'top ups’ and ‘co-payments’, threatening the fundamental principle of universal, free-at-the-point-of-need.
Alongside from the five year plan, other runes also point to an ominous direction of travel. It has just been announced that the much maligned 'work capability assessment' contract, given under the last Government to ATOS, is to be given to a company called Maximus, which makes large sums from providing 'long term care' packages in the US and beyond.
Recent proposals from Iain Duncan Smith and elsewhere in the conservative party have muddied the water between our universal healthcare and the highly conditional benefit system, looking to the highly contentious Australian system for inspiration. A DEMOS initiative, 'the power of prepaid', laid the groundwork last year, suggesting benefit and healthcare 'entitlements' could be merged on one card. Around the same time, Liam Byrne’s account of Jennie Macklin's work on benefits and health in Australia painted a rather different story in an Guardian article provocatively entitled “Let’s help disabled people fulfil their potential“.
Like a multi-national corporate document, the “5 year plan” is high on marketing but poor on strategy. It highlights of the ‘threat’ to the National Health Service from recurrent pay freezes to the majority of nurses. It's statement that "as the economy returns to growth, NHS pay will need to stay broadly in line with private sector wages in order to recruit and retain frontline staff,” has been interpreted as good news for NHS staff. But are pay increases really likely to be delivered by a Conservative Party Treasury with low taxes tattooed onto its ideological breast plate?
The report promotes 'personalised medicine’,
discussing how the NHS and “our partners” (ie the third and private sector)
might deliver the genome based ‘revolution’. There is no mention of the changes
in resource allocation which would be required to serve this revolution. Would
it see taxpayers subsidise the shareholder dividends or surpluses of large
corporate-like charities? There is no mention of the legal changes in the
legislative framework that would be needed, as in the United States, to prevent genetic discrimination. But here again the document serves its
marketing function – as a prospective prospectus for would-be investors wishing
to spot lucrative opportunities in the NHS as a data mine.
In any business strategy, one is obliged to think of the political, economic, social, technological, legal and environmental headwinds (affectionately known as “PESTLE” to business strategists).
Looking at the political headwinds, however, there is no mention of Labour's commitment to 'Whole Person Care'. Perhaps this isn’t surprising. The future of two of the Report’s contributing organisations themselves - Monitor and the Care Quality Commission - is on a knife edge. Labour's Oldham Commission suggested a single regulator should oversee health and care in future. Labour has already indicated it wants to scale back Monitor's role in enforcing competition. Burnham is contemplating whether Monitor should instead regulate the integration of services expected in Labour’s ‘Whole Person Care’ plans. Burnham tells us he intends to introduce ‘NHS preferred provider’, which could insist on the NHS being the ‘prime contractor’ in contracts lasting up to ten years.
But it’s fairly incredible the Stevens report contains no mention of trade agreements such as TTIP and the investor/state dispute settlement framework that many see as threatening the NHS.
If this ‘5 year forward plan’ had been at all serious, TTIP would have been included as a headwind which could drastically throw off course further the direction of travel of the NHS as a state-run health service.
Simon Stevens’ presents a ‘charismatic vision’ of sorts. But a vision does not have to be particularly credible for it to get populist appeal or succeed. It just needs to be communicated clearly, with supine and compliant supporters in the media.
If the document were a ‘heads up’ for how we could afford a NHS through general taxation which was genuinely universal and free at the point of need, it would have served a function.
As it is, the document is a lubricator for mechanisms which could optimise the part that the private sector has to play, with no mention of the dogs being unleashed in the global marketplace. It follows in the tradition of David Cameron refusing to signpost “the top down reorganisation”.
It is impossible for a strategy document for the NHS simply to airbrush out the political and legal factors which will be at play in the lifetime of the next Government. As it is, the NHS ‘5-year forward view’ is a basic piece of marketing, which as a strategic plan scores 0/10.
This is an edited version of an article that first appeared on the Socialist Health Association.
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