In the last ten days we have had Cameron’s Five pledges — (one of which was “we will not sell off the NHS”), the report of the Future Forum and Andrew Lansley’s response to their recommendations in the House of Commons. I listened to the Health Secretary’s speech in the House of Commons on 14th June and heard him say, “We will make it illegal to encourage the growth of one type of provider over another”, the very opposite of Labour minister Andy Burnham’s belated assurance in 2009 that the NHS would be the preferred provider. I could not believe that shadow health secretary John Healey did not take Lansley up on that even though he had been given the speech to read that morning.
The media blitz was expected and even BBC Newsnight’s Jeremy Paxman could not get Andrew Lansley to reveal the ultimate aim of this Bill, which is to turn the NHS into a commercial market. Much of the questioning has been superficial and, for example, Nick Du Bois, the conservative MP who has been most vocal in his criticism of the reported changes, said that Labour had introduced fund-holding. He was not challenged — it was of course Kenneth Clarke in his 1989 paper ‘Working for patients’ who did this. Frank Dobson abolished fund holding in the brief period when he was Secretary of State for Health in keeping with the Labour Manifesto of 1997 — “Our fundamental purpose is simple but hugely important: to restore the NHS as a public service working co-operatively for patients, not a commercial business driven by competition.”
The Newsnight programme, where five men discussed the pledges, was heavily weighted in favour of marketeers with Chaand Nagpaul, a GP on the BMA Council, barely able to get a word in edgeways between Norman Lamb, previous health spokesman for the Lib Dems, Andrew Bridgen, a conservative backbencher and Kingsley Manning responding to Jeremy Paxman’s questions. Kingsley Manning, business development director of outsourcing company Tribal, had greeted the White Paper last July with enthusiasm saying “This white paper could amount to the denationalisation of healthcare services in England and is the most important redirection of the NHS, going further than any Secretary of State has gone before.” He believes that the NHS is unsustainable, another argument being put forward by the Right to justify these sweeping changes.
On Tuesday morning’s BBC Radio 4 Today programme we heard Lord Warner, a previous NHS manager and Health Minister in the Labour government, saying that the model of District General Hospitals was outmoded but however much care you have in the community you still need hospitals for emergency and intensive care, surgery and sophisticated medical care for complex problems.
The things in the Bill which have not changed are:
The National Commissioning Board, a new quango
Monitor with extended responsibilities.
Strategic Health Authorities (SHAs) will be abolished.
Primary Care Trusts (PCTs) will be abolished.
The intention that all hospitals become Foundation Trusts (FTs). Presumably they are keeping the removal of the cap on private practice. (This was set at the income level when the hospital became a FT and is usually under 10% of income. If the cap is removed hospitals would be tempted to attract private fee-paying patients to generate income and this might lead to a two tier service.)
GP Consortia doing commissioning with the addition of 2 lay people, a nurse and a hospital doctor renamed Clinical Commissioning Groups-tokenistic rather than effective.
In response to the Future Forum’s recommendations not all hospitals will have to become FTs by April 2013 ; the new deadline is 2014 but those not ready by then will be given individual target dates. Similarly CCGs who are not ready by 2013 will have their commissioning function performed by local NCB groups. Recreating SHAs by another name?
These ideas are new:
Embed NHS constitution in the Bill and get NCB and CCGs to take active steps to promote the constitution. (This, published in 2010, outlines NHS values and the rights and responsibilities of patients and staff but does not give concrete figures about how quickly you should be treated for example.)
Clinical senates, groups of clinicians, to advise CCGs and NCB. They would be situated in the NCB.
Care Quality Commission must respond to advice from HealthWatch which is the patients advocacy service, not independent like Community Health Councils and situated within the CQC.
Public input into Monitor, the regulator, which initially was not to meet in public or publish minutes or have any lay representation.
New duty for Secretary of State (SoS) to promote research
Secretary of State retains duty to provide a comprehensive service wording as in 1946 Act but there’s a strange rider “though rather than securing services directly the SoS will be exercising his duty in future through the NHS bodies to be established.” Surely now he does not secure services directly but through the Department of Health, Strategic Health Authorities and Primary Care Trusts?
Governance arrangements of CCGs improved, they must take minutes and meet in public. With all the talk about openness and transparency and with large sums of public money, one would have thought this was obvious that the new commissioning groups should meet in public but despite attempts by the opposition the situation remained unchanged in the Committee stage.
Monitor’s core duty will be to ‘protect and promote patient’s interests’, removing its duty to ‘promote’ competition as if that were an end in itself.
CCGs as statutory bodies cannot delegate commissioning responsibilites to private companies or contractors. I see this as a sop to the LibDems and they probably hope it can be voted out at third reading. One Pathfinder GP consortium has already done this.
The document is designed to reassure the public that the government has taken on board the recommendations of the Future Forum but hidden in the 11 pages in the section on competition is this statement:
"We will outlaw any policy to increase the market share of any particular sector of provider. This will prevent current or future Ministers, the NHS Commissioning Board or Monitor from having a deliberate policy of encouraging the growth of the private sector over existing state providers – or vice versa. What matters is the quality of care, not the ownership model." My emphasis.
As Clive Peedell, an oncologist and BMA Council member says, “This statement is disguised as a control on privatisation, but note "or vice versa". This means the revised bill will outlaw the Government now, or in the future, from naming the NHS as preferred provider.”
I believed the listening exercise was a PR response to the growing chorus of dissent and outrage about the Bill -over 400,000 signatures collected by 38 degrees, the BMA’s and the RCN’s opposition, the TUC march with thousands demonstrating their anger about the cuts in a peaceful and good natured way with NHS banners prominent, and local marches, demonstrations and pickets cannot be ignored and have impinged on Cameron. Clegg, after signing of the White Paper and the Bill (apparently, according to Lib Dem health spokesman John Pugh, without having read them), was forced to respond to the demands of his own party led by Baroness Shirley Williams and Dr Evan Harris in March. The result of the May elections made him really try to get some changes but the LibDems are no match for the wily Tory politicians.
The Future Forum, billed as independent experts, were selected by whom? The listening events were aimed at the voluntary sector and ordinary people could not get to them except when the Guardian had one where Steve Field was 75 minutes late having been held up in his taxi after talking to David Cameron in Ealing. I managed to get to the London one in Islington and the whole room was skeptical about the Bill and these changes will not reassure the public. The poll commissioned by ITN showed that 49% of people do not think they can trust the Conservatives on health and half of the rest did not know what to think.
Lansley said after 99% of nurses at their conference passed a vote of no confidence in him ‘I am sorry if what I am setting out to do has not communicated itself” as if he had not been speaking all over the country to Radio and TV programmes and newspapers backed by a team of numerous press officers. But I think the absence of confidence is because he has not told us the truth about what his plans aim to achieve which is turn the NHS into a commercial market. We the English people do not want this and we must badger our MPs of all parties until they get the message.