We have been waiting to see whether - and how - new English NHS boss Simon Stevens would work round to furthering the private sector agenda he has brought with him from his sojourn at US insurance giant UnitedHealth – and now we know.
In a speech to the Local Government Association this week Stevens called for a major extension of combined health and social care personal budgets. The announcement opens up a whole range of opportunities for private insurers selling policies to cover top-up payments, and a host of cheapskate private service providers looking to cash in on a new £5 billion-plus market.
The Local Government Association should have been highly skeptical.
Incessant government cuts have forced them to make year after year of brutal cutbacks in adult social care budgets. For most people, there is next to no care now available for ‘moderate ‘social care needs, only for people with serious or critical needs. Much social care is delivered by exploited privatised staff on minimum wage, zero-hours contracts, meting out “care” in 15 minute episodes.
When it comes to finding cash for personal health budgets, the cupboard is bare.
Stevens stretched credulity when he told his audience that personal budgets would be a way to overcome the shortages of money which are increasingly visible in the NHS and social care.
In fact the establishment of personal budgets on the scale he now proposes – 5 million people, mostly receiving £1,000 each - in fact rips 20% or more out of the £30 billion a year currently spent on health and care of frail older people. All for giving people £20 per week - which won't go far, ripped out of the system, even at minimum wage levels.
It would empty the coffers of already-struggling NHS and council-run services, triggering a widespread collapse and closure of unsustainable services, resulting in even less choice, and in many areas no services at all for those who do not opt in to PHBs.
Personal Budgets are a way of carrying through the ultimate privatisation and fragmentation of care – right down to the individual. It completes the shift from state-funded and previously state-provided care, through to a partial state subsidy, leaving individuals organising their own care and footing an increasing share of the bills themselves. Apparently they are supposed to feel “empowered” in the process.
“Our Balkanised health and social care services are no longer fit for purpose”. Too many patient groups receive “inadequate and ‘fragmented’ care”, Stevens tells us.
For those on the receiving end, this is hardly news. But if the budgets of these main public services are inadequate now (and both face further real terms cuts for years to come) how can personal budgets solve the problem?
It’s the same feeble dregs in the jamjar – no matter how you divide it up or spread it, it still won’t make a decent sandwich.
In fact, it’s worse. How is state funding going to generate any more care if spent by individuals steering a difficult route between grasping private companies seeking to rip them off?
The answer to these riddles is unstated but obvious. When the personal budget runs out, those who can afford to do so will have to “top up” the miserly state contribution with their own money, or borrow from family and friends to pay the extra themselves.
Those who don’t, or who lack any savings or access to extra money will go without.
And there are more questions. How can five million individuals expect to get a “better deal” in negotiating one by one with private companies than they get from public services? Public services – whatever their faults – are driven by responsibilities to those who need care and support. Private companies are driven by the duty to deliver maximum return to their shareholders.
If older people are “baffled and daunted” by dealing with “an array of different parts of the NHS”, why would they not be equally or more baffled or daunted by being made responsible for buying their own care in a market place that will be thronged with low quality providers keen to make a fast buck?
The ground would be cleared for the private profiteers, who are happy to cash in on the limited choice of a large number of individuals trying to find their way through the chaos of the new system, possibly with the assistance of a voluntary sector ‘advisor’ and the local Yellow Pages.
Some voluntary sector organisations such as Age UK have opportunistically and uncritically jumped onto Stevens’ bandwagon scenting more empire-building possibilities ahead, just as the voluntary sector has now been harnessed in to back contracting out of cancer services and other “pathways of care”. They are doing their client groups no favours.
Eager testimony is retailed by ministers and voluntary sector enthusiasts citing the experience of selected individuals who were enlisted on early pilot schemes, given much more generous health budgets and who were willing and able to take matters into their own hands. But of course for the next five million these factors will increasingly not apply.
We’re at the end of a transition from institutional care, to care at home… to caring for yourself, on your own in your own home. That’s the glory of neoliberal Britain.
Stevens is a bright enough to know he’s talking nonsense when he claims that “individuals themselves can be the best ‘integrators’ of the health and social care they are offered”.
The imbalance of knowledge and power between even the most physically and mentally agile patients, and the providers of their health needs, means that a genuinely free market in health care is almost universally seen as impossible, and no country on earth has attempted to create one.
It’s clear that Stevens and the supporters of this policy – resting on anecdotes from a handful of individuals who have been able to do well from early pilots – are not interested in evidence such as the failed experiments with PHBs in the better-funded Netherlands system.
They appear to have also wilfully ignored evidence much closer to home. Back in 2011 the NHS Confederation published reports weighing up the merits of the scheme - and found strong concerns from service users, front line staff and carers.
They found “Service users in particular pointed out that even if given control of a budget, they would still be heavily dependent on their health professionals for expert advice …”. While a few NHS staff “spoke optimistically about PHBs allowing them to set up their own micro-providers”, the majority “expressed suspicion that this policy could destabilise current NHS services, replacing them with more for-profit providers.” “Frontline staff in particular foresaw a significant increase in the transaction costs of administering, brokering and monitoring health services under PHBs”.
Double running costs would arise from having to continue to run existing services for the majority while also finding the money to give to smaller numbers of patients to spend elsewhere.
“Service users wanted assurance that PHBs would not lead to the local services they valued closing down, leaving them, ultimately with less choice overall.”
In fact this was already happening in 2011. In South East London a successful community arts programme for people with mental health problems was forced to close by the financial insecurity of PHBs. There is now no equivalent service available to mental health service users. More closures have followed since.
The key selling point is always the same - Stevens suggests his plan would “keep people out of hospital, and ultimately save money”.
It might save George Osborne money if individuals are forced to dig into their own pockets to bridge the gaps and secure adequate services: but many will lack the money or the expertise to bridge the gaps and will fall through them, winding up in hospital, with even fewer options for discharge home again.
Stevens won’t care. He is now embarking on his real mission, to find the private sector serious returns from the wreckage of an NHS driven aground by Tory under-funding and marketisation.
He remains, as
many feared, the private sector’s man, now carving up the service that
superseded the private health care market. The fight is on to stop him.
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