Allyson Pollock cached version 17/02/2019 01:39:09 en Why the next Labour Manifesto must pledge to legislate to reinstate the NHS <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>Labour’s 2017 health manifesto was a hodgepodge of offers but failed to tackle the underlying issues. Bold thinking and a commitment to the NHS Reinstatement Bill - is needed now.</p> </div> </div> </div> <p><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//" alt="" title="" width="400" height="400" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_xlarge" style="" /></a> <span class='image_meta'></span></span></p><p>The 2017 Labour manifesto for health, like the road to hell, is paved with good intentions. </p> <p>Its pledges include improving children’s and mental health services, more funding for NHS and social care, tackling obesity and other public health prevention initiatives. However, unlike the Beveridge report of 1942, which considered the social determinants of health in the round, with its plan to slay the five giants of want, disease, ignorance, idleness and squalor, this manifesto for health has no public health framework. It is puzzling to see the issues of tackling unhealthy foods, obesity, physical activity, smoking and alcohol tucked under public health and the NHS, when what is required is an appreciation of the wider health political economy and the roles of industry and poverty. Redistributive policies are absent as are legislative actions, apart from on food labelling, advertising and a sugar tax.</p> <p>This health manifesto has cherry-picked the bits that those with the loudest voices have lobbied for, for example, the cancer fund, PrEP (pre-exposure prophylaxis), sexual health and HIV services, free hospital car parking, medicines review and regulation, the children of alcoholics, young smokers, mixed sex wards and special enquiries into blood contamination and the drug Valproate. It’s a jumble of ideas competing and jostling for priority. Each good intention is individually worthwhile but there’s no coherence as a strategy and no connection to rights to health and social determinants of health. What is missing is the big picture of what is really happening to the NHS, social care and public health.</p> <p><strong>The privatisation problem</strong></p> <p>Let’s start with the NHS and Social Care which are considered separately:</p> <p>“The next Labour government will reverse privatisation of our NHS and return our health service into expert public control. Labour will repeal the Health and Social Care Act that puts profits before patients, and make the NHS the preferred provider.”</p> <p>Care services have been relentlessly privatised over decades (See Pollock, 2005). The Health and Social Care (HSC) Act 2012 abolished and dismantled the NHS in England. Most social care and long-term care is delivered by for-profit companies and is means-tested. Public health has been pushed out to local authorities along with many sexual health, health promotion, HIV, and children’s services, and now the funding is being turned off and services closed. Long-term care has been almost completely privatised. These are structural changes. Yet Labour’s manifesto is virtually silent on the drastic and devastating system changes that have taken place as a result of the 1990 internal market and the 2012 Act. There is no whole-system approach, although the story that is being spun is one of integration of services and budgets.</p> <p>“The National Care Service will be built alongside the NHS, with a shared requirement for single commissioning, partnership arrangements, pooled budgets and joint working arrangements. We will build capacity to move quickly towards a joined-up service that will signpost users to all the appropriate services at the gateway through which they arrive.”</p> <p>There is nothing to differentiate these aspirations from the current Conservative administration’s articulation of its own policies. How exactly are sexual health, public health, mental health and children’s services, which are currently so fragmented - commissioned by so many different bodies and provided by a plethora of ‘providers’ - going to be reintegrated? How is long-term care provision, which is owned and operated by multinational for-profit companies, going to be integrated with publicly owned and publicly provided as well as privately operated health services? What are these partnership and joint working arrangements? How will pooled budgets and integration work, when NHS care is free and social care is charged for and means-tested? There is a marked disconnect in these aspirations.</p> <p>Most worryingly is the manifesto commitment to make the NHS the ‘preferred provider’, continuing the problematic purchaser-provider split and market elements in the NHS. Is there any intention to take long-term care and social care back into public ownership and control and to have national services? Rather, the commitment is to mitigating market excesses: the manifesto declares: “We will introduce a new legal duty on the Secretary of State and on NHS England to ensure that excess private profits are not made out of the NHS at the expense of patient care.”</p> <p>The manifesto makes no mention of commercial contracting being virtually legally compulsory for the NHS. What are excess profits - why have profits at all? In other words, the manifesto is committed to the status quo of commercial contracting, except for limiting excess profiteering. How exactly it is going to do that is a mystery.</p> <p>As for new legal duties, the primary establishing legal duty on the Secretary of State since 1946 has been to provide universal healthcare throughout. It was abolished in 2012. Why doesn’t the manifesto commit the party to restoring the duty to provide, rather than saying: “We will reinstate the powers of the Secretary of State for Health to have overall responsibility for the NHS.”</p> <p>On the <strong>workforce</strong>, the manifesto says: </p> <p>“To guarantee the best possible services for patients, Labour will invest in our health and care workforce. A Labour government will step in with a long-term workforce plan for our health service that gives staff the support they need to do the best for their patients.”</p> <p>Once again the manifesto fails to mention the enormous deregulation of terms and conditions that has occurred as a result of commercial contracting and the internal market. NHS Foundation Trusts are structurally 49% non-NHS and can set their own terms and conditions and determine staffing levels. In the mainly private for-profit long-term care sector, most employees are low-paid women and un-unionised. This is going to get worse under current government plans for partnerships.</p> <p><strong>Partnerships and fragmentation</strong></p> <p>Commercial contracts and joint ventures with the private sector are at the heart of the current government’s plans for radical changes to the NHS and its new models of care, termed Accountable Care Systems (ACSs) and Accountable Care Organisations (ACOs). Currently NHS England and Clinical Commissioning Groups (CCGs) are tendering for many thousands of contracts each year with multiple NHS providers and private companies bidding, all at great cost.</p> <p>In future this could reduce to a few hundred contracts. The Government plans to bundle up services into giant contracts which will be awarded by CCGs and local authorities to the above-mentioned ACOs. Organisations, known variously as Multi-speciality Community Providers (MCPs) and Primary and Acute Services (PACS) comprise these private and/or public NHS providers. These large contracts will be for ten years minimum. ACOs (MCPs and PACs) will in turn manage the risks and costs of care through subcontracts - which in turn may also sub-subcontract for services.</p> <p>NHS providers and private providers can form Special Purpose Vehicles (SPVs). According to accountants PWC, this is an</p> <p>&nbsp;“off-balance sheet vehicle comprised of a legal entity created by the sponsor or originator, typically a major investment bank or insurance company, to fulfil a temporary objective of the sponsoring firm. SPVs can be viewed as a method of disaggregating the risks of an underlying pool of exposures held by the SPV and reallocating them to investors willing to take on those risks. This allows investors access to investment opportunities which would not otherwise exist, and provides a new source of revenue generation for the sponsoring firm.”(1) </p> <p>So SPVs are a mechanism for bringing in private health insurers and property companies and investment bankers. This is what integration means in the market place – bundling up services into giant contracts and tendering them out. This Labour manifesto shows no sign of distancing itself from, and abolishing the market with necessary legislation.</p> <p>Labour is also committed to a new model of care: </p> <p>“We will work towards a new model of community care that takes into account not only primary care but also social care and mental health. We will increase funding to GP services to ensure patients can access the care they need. And we will halt pharmacy cuts and review provision to ensure all patients have access to pharmacy services, particularly in deprived or remote communities.”</p> <p>But Labour is utterly silent on how it will do this and how it will engage with the current Government’s radical ‘new models of care’ or joint ventures, through which it is transferring risks and its responsibilities for funding and providing services to private providers and ultimately patients. The manifesto’s references to partnerships and integration are ominous when there is no pledge to taking back public ownership and renationalising the NHS and social care. GP services are being cut and increasingly run by private for profit companies.</p> <p>“Labour will halt and review the NHS ‘Sustainability and Transformation Plans’, which are looking at closing health services across England, and ask local people to participate in the redrawing of plans with a focus on patient need rather than available finances. We will create a new Quality, safety and excellence regulator – to be called ‘NHS Excellence’.”</p> <p>Sustainability and Transformation Plans (STPs) and ACOs are the key mechanism for privatising NHS clinical services and for introducing alternative sources of funding for health care, namely health insurance and charges. Although there is as yet no legislation for STPs, ACSs and ACOs, the Government is pushing through these new organisational forms and contracts at breakneck speed, under the parliamentary radar and without public knowledge and consent, in order to bind the hands of future governments.</p> <p>NHS England has already appointed clinical leads and managers to many of the 44 STPs, and has spent over £20m on management consultants and staff.(2) For example, a contract worth £2.7m has been awarded to Capita by Nottinghamshire and Nottingham STP to support the area's sustainability developments. Capita in turn has subcontracted with Centene UK, an American insurance company, to provide expertise and run its STP as it moves to ACS status.(3) Centene's core business in the US is in the Medicaid Managed Care market, whereby private insurers control government budgets for the poor, contract with providers, and pocket the difference. Following some highly profitable acquisitions in the US, the company announced its intentions to expand abroad and already has a partnership arrangement with the Valencia government's corporate partner in the Alzira health service, Ribera Salud. Ribera Salud is currently under police investigation for corruption.(4)</p> <p>It's also been recently announced that Nottingham CCG has tendered a contract for community services worth £205m as part of the intended ACS. Given those now involved in the ACS formation, it can safely be assumed this will be awarded to a private company. At least eight other STPs are reported to be following suit in developing ACSs, and will receive £450m of transformation funding from NHS England.</p> <p>Halting and reviewing STPs is a first step but it won't go far enough: the changes are being driven by NHS England. The Labour manifesto is silent on the fact that most Foundation Trusts (FTs), which since 2012 have had new powers to enter into join ventures and to generate 49% of their income from private patients and other non-NHS sources, are entering into giant contracts of their own with property management companies.</p> <p><strong>Funding</strong></p> <p>“Labour will boost capital funding for the NHS, to ensure that patients are cared for in buildings and using equipment that are fit for the 21st century. And we will introduce a new Office for Budget Responsibility for Health to oversee health spending and scrutinise how it is spent.”</p> <p>But there is no mention in the manifesto of the crippling costs of the <strong>Private Finance Initiative</strong> (PFI). A recent study by the Centre for Health and the Public Interest calculated that £831m had been made in pre-tax profits by PFI companies over the past six years, money which has not been available for patient care. This figure is equivalent to at least a quarter of the total NHS hospital deficit over the same period.(5) </p> <p>The Department of Health’s annual capital budget has been frozen in cash terms over the five years to 2020-21. Much of its revenue funding has been rebadged as capital, for example, relabelled Research and Development revenue funding, depreciation and previously committed expenditure. Moreover it is being used to balance growing revenue deficits in the NHS Trust sector. In 2016-17 the DH Annual report and accounts reported that £1.2 billion of capital was moved to revenue expenditure in that year, a recurring pattern year on year.(6)</p> <p>To get around the lack of capital as well as the affordability, debt and deficit problems, FTs, especially those with PFI and deficits, are entering into various forms of joint venture in order to transform estate ownership and control. A hospital trust entering into an SPV with the clinical services income attached will have the additional attraction of being able to generate income from such services to pay the heavy debt charges and to raise borrowings for new capital using existing NHS property and to refinance PFI schemes.</p> <p>University College Birmingham NHS FT has, for example, recently linked up with the Healthcare Corporation of America (HCA) to build a mixed economy facility of 72 public and 66 private beds. According to the Trust, all capital has been provided by HCA. As an FT it can generate up to half its income privately. As such it is well positioned to become an ACO model. HCA currently has four joint ventures with NHS hospitals, including University College Hospital London and the Christie in Manchester.(7)</p> <p>Another form of joint venture, is the <strong>Strategic Estate Partnership</strong> (SEP). These 55 partnerships between the public and private sectors are intended to give the former greater control through non-exclusive contractual relationships where different stages of the process will be open to renewed tendering. In theory at least, this will mean a continual appraisal of value for money arrangements. In practice, however, SEPs are largely about maximising revenue creation in as many ways as possible, including developing retail outlets, car parking, patient hotels, sales and disposals, and private patient units.(8) Indeed many former PFI companies, such as Interserve, Prime and the Rydon Group, have simply transferred their attention to this new model which, given the scale of investment opportunities involved, could be considered a type of ‘<strong>PFI Plus</strong>’.</p> <p>There are currently more than eight SEPs reported on commercial and contracting websites, though it is hard to find any detail on Department of Health and NHS websites. The first SEP was at Lancashire Care Foundation Trust, with others now including Cheshire and Wirral Partnership FT, University Hospital Southampton FT, Isle of Wight Trust, Yeovil District Hospital FT and one at Hinchingbrooke following the collapse of Circle’s management of the Trust. Several more are in the pipeline. These include North West Anglia NHS FT, Oxleas NHS FT, and Whittington Hospital NHS Trust. </p> <p>The Labour manifesto does not mention the <strong>selling off of NHS assets</strong> to create revenue for the Treasury. Yet a key attraction of joint ventures, which allow investment bankers and property management companies to partner in health care, is the sale and disposal of NHS assets. Since the HSC Act 2012, the government has paved the way for privatisation of non-FT estate with the abolition of NHS Estates and creation of two Department of Health-wholly owned companies, NHS Property Services and Community Health Partnerships. NHS Property Services holds the estate of Primary Care Trusts and Strategic Health Authorities which was not transferred to trusts and is among the largest property owners in Europe. It is now charging exorbitant <strong>market rents</strong> to the NHS and GPs, to such an extent that small GP practices are closing and trusts and CCGs are struggling to pay. Community Health Partnerships includes 49 Local Improvement Financial Trust Companies with investment of £2.5 billion and 339 facilities involving 29 companies.</p> <p>NHS England has created six regional public-private partnerships to help speed up disposals, and once approval has been obtained, these will be advertised in the Official Journal of the European Union in six lots worth more than £3bn. Codenamed <strong>Project Phoenix</strong>, “private companies will work with the NHS to achieve the best market price for the sales without the requirement of upfront public investment, with profits shared between the NHS and its private partners. Details of the profit split have yet to be revealed”, according to the Health Service Journal.(9) In August this year Primary Health Properties, Octopus Healthcare and Assura came forward with a combined offer of £3.3bn of investment, which they say would provide the entire private capital necessary to embed STP plans and fund up to 750 new primary care centres at an approximate rental value of £200m per annum. All three companies incorporate both investment and property arms and are based offshore.(10) According to a LaingBuisson market report on primary care from 2015, the three companies, at a combined aggregate of £2.27bn, already had a 19% share of the estimated asset value of all GP premises in the UK.(11) Harry Hyman, managing director of Primary Health Properties, has been quick to say that this is not a form of PFI, rather a “continuation of our business model where we own the properties and rent them for the period of the lease.”(12) </p> <p>The manifesto makes four pledges for increasing funding: </p> <p>“We will increase the social care budgets by a further £8 billion over the lifetime of the next Parliament, including an additional £1 billion for the first year. This will be enough for providers to pay a real living wage…Labour will commit to over £30 billion in extra funding over the next Parliament through increasing income tax for the highest 5 per cent of earners and by increasing tax on private medical insurance, and we will free up resources by halving the fees paid to management consultants.”</p> <p>Of course more funding is necessary. By 2015–16, NHS commissioners, NHS trusts and NHS FTs reported a combined deficit of £1.85 billion, a greater than threefold increase in the deficit position of £574 million reported in 2014–15. Provider trusts’ overall deficit grew by 185% to £2.45 billion, up from £859 million in 2014–15, against a total income of £75.97 billion.</p> <p>In addition, two-thirds of NHS trusts (65%) and NHS FTs (66%) reported deficits in 2015-16, up from 44% of NHS trusts and 51% of NHS FTs in the previous financial year. The number of CCGs reporting cumulative deficits was 32 in 2015–16, up from 19 in both 2014–15 and 2013–14.(13) </p> <p>However, the Labour Manifesto fails to address where the money is going, namely the transactions costs of the market (12-30%), the high costs of PFI and prices of drugs and technologies which rise ahead of NHS pay and the costs of management consultants. It is silent on the enormous costs of administering a market, a market which it plans to retain, stating only that it will free up resources by halving the fees paid to management consultants.</p> <p><strong>The NHS Reinstatement Bill</strong></p> <p>Most surprisingly, the manifesto makes no mention of what will replace the HSC Act 2012 and no mention of the NHS Reinstatement Bill, which Jeremy Corbyn and John McDonnell supported before becoming leader and shadow chancellor respectively. This Bill has been tabled three times in the House of Commons, most recently by Margaret Greenwood MP.</p> <p>Diane Abbott, in her brief tenure as shadow health secretary, told Bill supporters outside parliament that Jeremy Corbyn had made a point of returning to the Commons to be present for the debate. It appears that the lack of manifesto commitment to the Bill comes from quarters within Labour other than Corbyn and his allies. The next Labour manifesto must now remedy the catastrophe that is unravelling and commit to the NHS Reinstatement Bill.(14) Unless this happens, there will be no NHS.</p> <p>The Bill proposes to fully restore the NHS as an accountable public service by reversing 25 years of marketisation in the NHS, abolishing the purchaser-provider split, ending contracting and re-establishing public bodies and public services accountable to local communities. This is necessary to stop the dismantling of the NHS under the HSC Act 2012. It is driven by the needs of local communities. Scotland and Wales have already reversed marketisation and restored their NHS without massive upheaval. England can too.</p> <p>The Bill provides flexibility in how it would be implemented, led by local authorities and current bodies. It would:</p> <p>- reinstate the Government’s duty to provide the key NHS services throughout England, including hospitals, medical and nursing services, primary care, mental health and community services,</p> <p>- integrate health and social care services,</p> <p>- declare the NHS to be a “non-economic service of general interest” and “a service supplied in the exercise of governmental authority,” so asserting the full competence of Parliament and the devolved bodies to legislate for the NHS without being trumped by EU competition law and the World Trade Organization’s General Agreement on Trade in Services,</p> <p>- abolish the NHS Commissioning Board (NHS England) and re-establish it as a Special Health Authority with regional committees,</p> <p>- plan and provide services without contracts through Health Boards, which could cover more than one local authority area if there was local support,</p> <p>- allow local authorities to lead a ‘bottom up’ process with the assistance of CCGs, NHS trusts, NHS FTs and NHS England to transfer functions to Health Boards,</p> <p>-&nbsp; abolish NHS trusts, NHS foundation trusts and CCGs after the transfer </p> <p>- abolish Monitor – the regulator of NHS FTs, commercial companies and voluntary organisations – and repeal the competition and core marketsation provisions of the 2012 Act,</p> <p>- integrate public health services and the duty to reduce inequalities, into the NHS,</p> <p>- re-establish Community Health Councils to represent the interest of the public in the NHS,</p> <p>- stop licence conditions taking effect which have been imposed by Monitor on NHS foundation trusts and which reduce the number of services they currently have to provide,</p> <p>- introduce a system for collective bargaining across the NHS,</p> <p>- centralise NHS debts under the PFI in the Treasury, require publication of PFI contracts and also require the Treasury to report to Parliament on reducing NHS PFI debts,</p> <p>- abolish the legal provisions passed in 2014 requiring certain immigrants to pay for NHS services</p> <p>- declare the UK’s agreement to the proposed Transatlantic Trade and Investment Partnership and other international treaties affecting the NHS to require the prior approval of Parliament and the devolved legislatures,</p> <p>- require the Government to report annually to Parliament on the effect of treaties on the NHS.</p> <p><strong>Conclusion</strong></p> <p>By 2011 David Bennett the former head of Monitor, the economic regulator of the NHS, was telling the <em>Times</em>: “The NHS is ripe for dismemberment.”(15) He declared to the House of Commons health select committee: “We, in the UK, have done this in other sectors before. We did it in gas, we did it in power, we did it in telecoms… We've done it in rail, we've done it in water, so there's actually 20 years of experience in taking monopolistic, monolithic markets and providers and exposing them to economic regulation.”(16)</p> <p>On Sep 27th 2016, Diane&nbsp;Abbott, then shadow health secretary, stated at the Labour Party conference:<br /> “Under Jeremy Corbyn's leadership, the Labour Party will be committed to halting and reversing the tide of privatisation and marketisation of the NHS. The Health and Social Care Act has fragmented the system, making it so much easier for the private sector to move in. Conference, Labour in government will repeal the Health and Social Care Act. This means returning our NHS to what is was originally conceived as: a publicly owned, publicly funded, publicly accountable universal service as outlined in the NHS Reinstatement Bill now being expertly piloted through Parliament by my colleague Margaret Greenwood, MP for Wirral West, with the support of the Labour leadership.”(17)</p> <p>We must all hold the Labour Party to that pledge.</p> <p>&nbsp;</p> <p>The author wishes to acknowledge the help of Stewart Player for his contribution to the analysis of NHS estates.</p> <p>References</p> <p>Allyson M Pollock, <em>NHS PLC: The privatisation of our health care</em> (Verso, 2005). </p> <p>Footnotes</p> <p>(1) <span><a href=""></a></span> </p> <p>(2) See for example: <span><a href=""></a></span>&nbsp; and <span><a href=""></a></span> </p> <p>(3) <span><a href=""></a></span> </p> <p>(4) <span><a href=""></a></span> </p> <p>(5) <span><a href=""></a></span> </p> <p>(6) <span><a href=""></a></span> </p> <p>(7) <span><a href=""></a></span> </p> <p>.(8) See for example: <span><a href=""></a></span> </p> <p>(9) <span><a href=""></a></span> </p> <p>(10) <span><a href=""></a></span> </p> <p>(11) LaingBuisson, Primary Care &amp; Out-Of-Hospital Services, Second Edition, 2015)</p> <p>(12) <a href=""></a> </p> <p>(13) <span><a href=""></a></span> </p> <p>(14) <a href=""></a> </p> <p>(15) <a href=""></a> </p> <p>(16) <a href=""></a> and <span><a href=""></a></span> </p> <p>(17) <a href=""></a></p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/caroline-lucas/i%E2%80%99m-proud-to-have-presented-crossparty-nhs-reinstatement-bill-in-parliament">To save our health service MPs must stand together and back the NHS Reinstatement Bill</a> </div> </div> </div> </fieldset> <div class="field field-rights"> <div class="field-label">Rights:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> CC by NC 4.0 </div> </div> </div> ourNHS uk ourNHS Allyson Pollock Tue, 12 Sep 2017 08:17:21 +0000 Allyson Pollock 113307 at BMA backs principles of NHS Reinstatement Bill to save NHS from destruction by market forces <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>As politicians squabble over NHS funding figures, the British Medical Association's Council has backed the principles of radical legislation which would get the costly 'market' out of the NHS.</p> </div> </div> </div> <p class="MsoNormal"><span class='wysiwyg_imageupload image imgupl_floating_none 0'><a href="//" rel="lightbox[wysiwyg_imageupload_inline]" title=""><img src="//" alt="" title="" width="460" height="421" class="imagecache wysiwyg_imageupload 0 imagecache imagecache-article_xlarge" style="" /></a> <span class='image_meta'></span></span><em>Professor Allyson Pollock, member of the BMA Council and their working group examining neccessary legal changes.</em></p><p class="MsoNormal"><span>The stated policies of the</span><span>&nbsp;</span><span>British Medical Association are to end the market in health care, oppose the purchaser provider split, and to reinstate the Secretary of State’s duty to provide universal health care throughout England.</span><span>&nbsp;</span></p> <p class="MsoNormal"><span>The BMA has made its position clear - not only in its <a href="">general election briefings</a> but in full page advertisements where it has declared that its doctors support a “<a href="">publicly funded, publicly provided</a>” NHS.</span></p> <p class="MsoNormal"><span>The BMA has now gone as far as setting out the principles of the legislation it would expect to see after the election.</span></p> <p class="MsoNormal"><span>&nbsp;On 11th March 2015, the BMA’s Council completed its examination of two sets of legislative proposals on the NHS set out in Private Member’s Bills laid before the House of Commons.&nbsp;</span></p> <p class="MsoNormal"><span>The purpose of its examination was to analyse two bills - the NHS (Amended Duties and Powers) Bill, presented by Labour MP Clive Efford and supported by 11 Labour MPs; and the proposed NHS Reinstatement Bill subsequently presented – on 11th March 2015 –&nbsp;<strong>as the NHS Bill 2015</strong>&nbsp;by Green MP Caroline Lucas and supported by 11 Liberal Democrat, Labour, SNP and Plaid Cymru MPs.</span></p> <p class="MsoNormal"><span>The BMA Council established a large working group, of which I was a member, to identify which proposals in the Bills were in line with and would further BMA policies.</span></p> <p class="MsoNormal"><strong><span>In response to the reports of that working group the Council unanimously agreed to support legislation which furthers implementation of strong and clear policies of the Association concerning:</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• restoration of the Secretary of State’s duty:</span></strong><span></span></p> <p class="MsoNormal"><strong><span>o to provide and secure provision of services in accordance with the National Health Service Act 2006 for the purpose of the comprehensive health service that it is his or her duty to promote, and</span></strong><span></span></p> <p class="MsoNormal"><strong><span>o to provide listed services throughout England under section 3 of that Act,</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• limits on the Secretary of State’s powers over operational matters and day-to-day running of the health service,</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• abolition of the purchaser-provider split, the internal and external market and competition,</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• the ending of PFI in the NHS,</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• the exemption of the NHS from TTIP, and</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• the moral unacceptability of the Immigration Health Charge,</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• ensuring public accountability</span></strong><span></span></p> <p class="MsoNormal"><strong><span>• supporting national terms and conditions.</span></strong><span></span></p> <p class="MsoNormal"><span>BMA Council also unanimously insisted that where legislation to abolish the purchaser-provider split, the internal and external market and competition involves structural changes the legislation must be implemented in a flexible and devolved way in order to minimize concerns about potential disruption that might result from implementation of those policies.</span></p> <p class="MsoNormal"><span>BMA policy is made by the annual representatives at its Annual Representative Meeting.&nbsp;</span></p> <p class="MsoNormal">The BMA is not alone. The King’s Fund has recognised the<span> ‘</span><a href=""><span>disastrous’</span></a><span> impact of the Health &amp; Social Care Act, reporting recently that s</span><a href=""><span>ervices are deteriorating faster</span></a><span> than at any time since the early 90s, with waiting lists at a record high, morale low, and GP and mental health services under severe strain. </span></p> <p class="MsoNormal"><span>Another Kings Fund report released in the last month has</span><span> also set out how </span><a href=""><span>without a re-organisation that scraps the autonomous nature of Foundation Trusts</span></a><span class="MsoHyperlink"><span>,</span></span><span> it will be impossible for the NHS to avoid EU competition law (even without TTIP).</span><span></span></p> <p class="MsoNormal"><span>There is growing concern too over </span><a href=""><span>Osborne’s surprise announcement</span></a><span>&nbsp;which would shift £6bn of NHS and social care funding and decision making to the yet to be elected Manchester mayor. Responding to that announcement, Dr Mark Porter, Chair of the British Medical Association, said:</span></p> <p class="MsoNormal"><span>&nbsp;</span><span>“We need assurances on who is responsible if these changes go wrong.</span><span>&nbsp;Doctors believe the Secretary of State for health should have the duty to provide a universal and comprehensive health service.”</span></p> <p class="MsoNormal"><span>Only legislation will do this. And the principles of what is needed is set out in the NHS&nbsp;Bill 2015, which is the product of over two years work by the Campaign for NHS Reinstatement.</span></p> <p class="MsoNormal"><span>It is highly significant that the BMA has said it will support legislation to support its policies. Now it is up to voters to demand that their candidates support the NHS Bill 2015 and the legislation required to restore the duty to provide in the first Queen’s Speech of a new parliament. There is very little time left. </span></p> <p class="MsoNormal"><span>To contact your parliamentary candidates please visit </span><a href=""><span></span></a><span> and TAKE ACTION.</span><span>&nbsp;</span></p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/caroline-molloy/new-law-proposed-to-stop-nhs-becoming-simply-memory">New law proposed to &quot;stop the NHS becoming simply a memory&quot;</a> </div> <div class="field-item even"> <a href="/ournhs/caroline-molloy/efford%27s-save-nhs-bill-does-it-do-what-it-says-on-tin">Efford&#039;s &quot;Save the NHS&quot; Bill - does it do what it says on the tin?</a> </div> </div> </div> </fieldset> ourNHS uk ourNHS Allyson Pollock Tue, 14 Apr 2015 11:30:01 +0000 Allyson Pollock 91983 at Parliament must tackle commercial interests to save public health data <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>The controversial care data programme - debated in parliament today - must be amended to ensure public, not private interests come first, and restore public trust.</p> </div> </div> </div> <p class="MsoNormal"><span>Public trust in the government looking after our NHS data is at an all-time low following revelations that health care data were being sold on to large commercial organisations for insurance purposes and of serious data breaches of identifiable patient data leaking into the public domain. It resulted in the BMA, RCGPs and medConfidential spear-heading an opt-out campaign against government plans to link England-wide aggregated patient data collected from GP practices with hospital admissions/ episode data in a scheme know as On 7&nbsp;May, Parliament has a chance to start listening. </span></p><p class="MsoNormal"><span>Commercial exploitation of data is not new. We allow supermarkets, train companies, utilities and banks to use our data in return for nectar points, loyalty cards and the like. But since the time of Hippocrates, information about patients has been recognized as special and sacrosanct. </span></p><p class="MsoNormal"><span>Doctors are bound by a special duty of confidentiality. Laws underpin it. We go to our doctors when we are at our most vulnerable. We share our innermost thoughts and worst fears. Terminal illnesses, miscarriages, sexually transmitted diseases, domestic violence, unemployment or work stresses are ‘routine’ diagnoses for the medical profession, yet they are also deeply personal and often tragic for the patient. </span></p><p class="MsoNormal"><span>Sharing these with trusted doctors and health professionals is a big step for many. Knowing that commercial companies could exploit what we or the doctor might say – for example, to decide whether we or others are too costly to treat, or to target marketing of drugs, health insurance or user charges – makes that big step even bigger.&nbsp;</span></p><p class="MsoNormal"><span>For over 60 years the NHS has cherished and protected our data through public ownership and control and strong legal safeguards. Aggregated data has flowed for public interest purposes – such as to the national Statistics Authority and to cancer registries, and to generate public health statistics to inform planning, medical audit and monitoring of inequalities. There are no recorded incidents of researchers having abused their privileged access.</span></p><p class="MsoNormal"><span>But public trust has now been undermined by the government decision to deliver&nbsp;NHS care through a market. Billions of pounds of NHS money are now flowing to companies such as Serco, Group4, Virgin and United Health – even to private insurance companies. </span></p><p class="MsoNormal"><span>In 2012 the government scrapped its legal duty to secure a comprehensive health service. </span></p><p class="MsoNormal"><span>These companies can provide <a href="">both NHS-funded and privately-funded care</a> to the same patient and in the same episode of care, regardless of need or ability to pay. So what happens to our NHS data where it is generated through commercial transactions and will be collected, stored and used by the private sector? </span></p><p class="MsoNormal"><span>True, a patient can consent for their data to be used, but&nbsp;in a vulnerable position it is a brave patient who will refuse consent if they are told it will help coordinate and plan their care or that lack of data might prevent the best care being made available. Opting in will destroy national statistics built up over more than a century and will seriously impair research into the patterns and causes of diseases, access to care&nbsp;and the effectiveness of interventions over the long term. Opting- out may have similar consequences.</span></p><p class="MsoNormal"><span>But if we agree to share our data with the private sector what happens to the data afterwards? What is to stop Virgin or Group 4 selling on our data that is generated through commercial contracts with NHS commissioners, or using it to help set up patient charges and insurance?</span></p><p class="MsoNormal"><span>Under the old rules, confidential patient data was basically allowed to be shared for two reasons only – for national statistics and for medical purposes (known as “Section 251 approvals”). Section 251 approvals allow research and monitoring of infectious diseases, cancers and various other purposes but only by health professionals and their equivalents. </span></p><p class="MsoNormal"><span>Part 9 of the Health and Social Care Act 2012 opened up commercial access by allowing companies to request the establishment of information systems for their use. NHS England has already told the Health and Social Care Information Centre (HSCIC) to require care providers to upload identifiable data. </span></p><p class="MsoNormal"><span>Once at HSCIC our data can be sold on to companies if “in connection with the provision of health care or adult social care”. Unlike the old “medical purposes” exemption, this new formulation is so vague and ill-defined it can extend to insurance and marketing, billing and invoicing, and targeting eligible and ineligible patients. One patient’s data can be used to deny others care. In other words, the government has made patient data into an asset to be traded in the market place, equating the public interest with commodification.</span></p><p class="MsoNormal"><span>The pharmaceutical companies and commercial sector argue that great gains can come from having access to patient data. Even if this were true, there is legal provision for this already in section 251. Every other researcher and research institution has to seek section 251 approvals now, so there is no need to expand the provisions to wider purposes. And separate laws govern drug trials in any case.</span></p><p class="MsoNormal"><span>So what is to be done to the Care Bill on 7 May? Everything flows from the law. All commercial exploitation of data has to stop and be put on hold. Private companies cannot be free to sell on our data and trade it on the open market.</span></p><p class="MsoNormal"><span>In the long term we need to think hard about the impact of commercialisation of services and data on the public interest. </span></p><p class="MsoNormal"><span>For now, we’ve <a href="">proposed three amendments</a> for the <a href="">Lords to consider</a>. Public trust cannot be expected without legal measures to protect patients and our data from being exploited for private gain. We argue that can only happen if patients give their consent to this, although the meaning of consent when given from a position of vulnerability is itself questionable, and that research can only take place if it is in the public interest and for medical purposes as set out in Section 251. We also insist on keeping parliamentary, or at least independent, oversight of the HSCIC’s operation, under the auspices of the Information Guardian. The Committee which oversees 251 approvals cannot be stretched to do this.</span></p><p class="MsoNormal"><span>The Academy of Royal Medical Colleges made up of 21 Medical Colleges met last week to discuss how to restore public trust. They and the statistical bodies must now give their backing to strong legislation which will put the public interest and patients before commercial interests. If they fail to do this, they will themselves further dent public trust and confidence in the government’s system for the protection of patient information.</span></p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/caroline-molloy/three-crucial-safeguards-for-medical-records-proposed-by-leading-voices-on-ca">Three crucial safeguards for medical records proposed by leading voices on </a> </div> <div class="field-item even"> <a href="/ournhs/allyson-pollock-alison-macfarlane/opting-out-of-caredata-is-not-answer">Opting out of is not the answer</a> </div> </div> </div> </fieldset> ourNHS uk ourNHS Allyson Pollock Wed, 07 May 2014 12:12:15 +0000 Allyson Pollock 82575 at Opting out of is not the answer <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>Mistrust of is not surprising, given the corporate interests involved - but simply opting out will make it even harder to monitor the impact of privatisation on Britain's health.</p> </div> </div> </div> <p class="MsoNormal"><span>NHS England has sent a leaflet ‘Better information means better care’, sent to every household in England. This has triggered a campaign to encourage people to opt out of the new system by telling their GP that they do not want their health records uploaded to it.</span></p><p class="MsoNormal"><span>Opting out will undermine both the new system and our existing national statistics as well playing into the hands of the private sector. It means data will be inadequate to assess the impact of government policies to privatise the NHS.&nbsp;</span></p><p class="MsoNormal"><span>The aim of is to link together coded records from general practice with data from other national data systems, starting with linkage to existing ‘Hospital Episode Statistics’. The plans are to provide “linked data, that will eventually cover all care settings, both in and outside of hospital.” This is explained by the <a href="">Health and Social Care Information Centre</a> at</span><span>&nbsp;</span><span>and&nbsp;</span><span><a href="">NHS England</a>.</span></p><p class="MsoNormal"><span> should not be confused with </span><a href="">Summary Care Records</a><span>, which enable clinical information to be shared between individual patients and the professionals who provide care to them. There are no plans to upload these records into</span></p><p class="MsoNormal"><span>Although England has had NHS hospital data analysed at a national level for a long time, this has not been the case with data from general practice, where most care takes place.&nbsp;</span><span>England is well behind Scotland and Wales both in data linkage and in engaging with the public about it.</span></p><p class="MsoNormal"><span>To address this, the <a href="">GP Extraction Service</a> was set up in 2011 with a budget of £40 million to extract data from general practice systems and analyse them at a national level for England.&nbsp;</span></p><p class="MsoNormal"><span>If this and the further data linkage work, it would provide valuable population-based statistical information for commissioners, public health and for researchers. It would allow us to monitor inequalities in access and unmet need and changes in rates of heart disease and cancer, for example.</span></p><p class="MsoNormal"><span>The system will cost over £50million.&nbsp;</span><span>It is unclear from the information on its web site whether this includes any routine analyses to be done in-house and made publicly available as national statistics.</span></p><p class="MsoNormal"><span>Meanwhile cuts of £9million to the Office for National Statistics include cuts of £1million in its statistical outputs which will lead to the loss of a range of highly regarded health statistics. There is also an uncertain future for the decennial Census, which dates back to 1801 in England and Wales and is essential for public health as it provides data on the whole population.</span></p><p class="MsoNormal"><span>There are justifiable concerns that the government is preparing the way for the commercial exploitation and use of&nbsp;our NHS data and that the private sector will have priority in accessing the data for analysis.</span></p><p class="MsoNormal"><span>The person in charge of, in his role as National Director for Patients and Information at NHS England, is former Sunday Times journalist Tim Kelsey. Kelsey is also the founder of Dr Foster, a company which has been the subject of a critical parliamentary Public Accounts Committee enquiry. Dr Foster analyses NHS patient data then sells back the analyses to the NHS organisations which collect the data.</span></p><p class="MsoNormal"><span>Roger Taylor, co-founder of Dr Foster, has&nbsp;been appointed to a senior role in the Care Quality Commission. Kingsley Manning has been appointed Chair of the Health and Social Care Information Centre. Manning’s former roles were as head of health at outsourcing firm Tribal, and before that founder and managing director of health and information consultancy firm Newchurch, which provided advice on PFI and sell off of NHS assets.</span></p><p class="MsoNormal"><span>These corporate appointments are akin to putting bankers in charge of NHS hospitals.&nbsp;</span></p><p class="MsoNormal"><span>To make matters worse, Clinical Commissioning Groups do not analyse data in-house to inform their decisions. Since the Health and Social Care Act came into force, vital information functions have been outsourced to Commissioning Support Units, organisations which have no basis in law and are temporarily hosted by NHS England. Plans to float these organisations on the stock market have been suspended in favour of turning them into social enterprises, staff mutuals, customer controlled social enterprises or joint ventures. Clinical Commissioning Groups should demand that these information functions and the associated NHS funds and staff be returned to them before any privatisation takes place.</span></p><p class="MsoNormal"><span>Campaigners are concerned that pharmaceutical industry and health insurance companies will be simply ‘given’ the data.</span></p><p class="MsoNormal"><span>Section 251 of the NHS Act 2006 <a href="">requires</a> them to state what uses will be made of data and how they will be stored securely. They will also have to answer similar questions from the Health and Social Care Information Centre’s&nbsp;<a href="">Data Access Advisory Group</a>. Applicants do not ‘own’ the data but can use them. This still raises serious questions about the purposes to which the data will be used and the extent to which analyses may be sold on. There is still no clarity or transparency about the ownership and control of the data, how the data will be accessed and used by the private sector or how statistics about NHS-funded private care will be made available to all.</span></p><p class="MsoNormal"><span>We need reassurance from government that the data will be used to produce and publish national statistics in line with the <a href="">National Statistics Code of Practice</a>. The Code, overseen by the UK Statistics Authority, is designed to be observed by all the public bodies that produce official statistics. It is trustworthy and trusted, and considered to be central to maintaining a unified statistical service that meets the needs of government and society.</span></p><p class="MsoNormal"><span>As the government is privatising health care, it is crucial to have complete and high quality data to monitor the impact of these policies. The private sector has a poor track record for&nbsp;data collection. The atrocious quality of private sector data returns made it impossible to monitor contract compliance for independent sector treatment centres,&nbsp;the government’s £4 billion programme for elective surgery, where NHS funds were diverted to for-profit providers. General practices owned by private companies such as Virgin and Serco will be protected from scrutiny if their patients opt out, as there will be no data about them. This gap already exists in private nursing and residential care homes.</span></p><p class="MsoNormal"><span>Instead we need a public campaign to promote public data and oppose privatisation of both our healthcare services and data functions.</span></p><p class="MsoNormal"><span>Patients and the public need to make it clear to NHS England that their consent for medical records to be uploaded to is conditional on it not being used for commercial purposes or handed over to third parties such as drug companies and health insurance and health care corporations. </span></p><p class="MsoNormal"><span>Such a campaign must make links between opposing the privatisation of the data collection and analysis systems and opposing the privatisation of our health services. We must ensure that NHS England and Clinical Commissioning Groups oppose both.</span><span>&nbsp;</span></p><p>&nbsp;</p><p class="MsoNormal">&nbsp;</p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/jane-fae/sleepwalking-into-information-grab-by-private-health">Sleepwalking into an information grab by private health?</a> </div> <div class="field-item even"> <a href="/ournhs/jane-fae/your-medical-data-in-their-hands-concerns-mount-over-new-nhs-it-project">Your medical data in their hands - concerns mount over new NHS IT project</a> </div> <div class="field-item odd"> <a href="/ournhs/phil-booth/your-medical-data-on-sale-for-pound">Your medical data - on sale for a pound</a> </div> </div> </div> </fieldset> <div class="field field-country"> <div class="field-label"> Country or region:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> UK </div> </div> </div> ourNHS uk ourNHS UK Big Data Technology and privacy Alison Macfarlane Allyson Pollock Fri, 31 Jan 2014 11:49:02 +0000 Allyson Pollock and Alison Macfarlane 78959 at Why we need a political campaign to reinstate the NHS in England <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>This extract is from the forthcoming publication on the future of the national health service for <a href="">the Centre for Labour and Social Studies (Class)</a></p> </div> </div> </div> <div class="entry-content"> <p><em>(This article originally appeared at <a href="">Left Foot Forward</a>, cross-posted with thanks)</em></p><p>At 2.36 on the afternoon of Tuesday 27 March, 2012 the Health and Social Care Bill 2011, repealing the legal foundations of the NHS in England, was given royal assent and became law.</p> <p>Campaigning groups, NHS staff and professional organisations had fought for nearly 2 years against what must count as one of the most regressive pieces of UK legislation of the last 60 years.</p> <p>That the bill became law in the end is testimony not to our robust democratic processes <strong>but to the autocratic power of government</strong>. The coalition came to office in May 2010 on a manifesto promising no further top-down reform of the NHS, and then promptly did the opposite.</p> <p><span>&nbsp;</span>The bill passed into law without an electoral mandate because no major political party or parliamentary institution in England was willing or able to defend the NHS. It was a constitutional outrage. Its passing marked the end of a National Health Service in England that for more than sixty years served as one of the most successful models in the world, widely praised and copied.</p> <p>The UK NHS was created by national consensus <strong>in order to ensure that every citizen was guaranteed health care. </strong>Underpinning these arrangements was the secretary of state’s core duty to provide or secure a comprehensive health service, a duty repealed by the first clause of the Health and Social Care Act.</p> <p>Repeal was the fulcrum of the free market agenda because the duty compelled the minister to allocate resources according to need instead of leaving allocation to market forces and unaccountable organisations.</p> <p>In the absence of a ministerial responsibility, it now becomes possible to blur the boundaries between free health care and chargeable health and social care. Many NHS services are being transferred to local authorities, which can charge for care.</p> <p>The Act also <strong>abolishes rules that make certain health services mandatory</strong>. Under this system, players in the health care market can choose the services they wish to provide and the patients for whom they provide.</p> <p>The principle is not, as the coalition repeatedly claimed, increased patient choice but increased choice of patient.</p> <p>The NHS has been<strong> an international model</strong> because it provided what no other country in the world has achieved at the same cost: universal health care in the form of equal access to comprehensive care irrespective of personal income.</p> <p>For most of its existence the NHS was based on the principle that the poor, the chronically sick and the frail elderly would receive the best available care only if the rich received the same service. Since the 1970s and throughout the 1990s, we have witnessed a dismantling of publicly-funded and provided long-term care including nursing care for the elderly and the huge inequalities that have accompanied it.</p> <p>As the 2012 Act is being implemented, corporations will have more say in determining our entitlement to free health services. In future, no single organisation will be responsible for ensuring the health care of all residents within an area and it will no longer be clear who should be held accountable when things go wrong.</p> <p>Our relationship with our doctor will change when for-profit companies run more services. According to the <em>Financial Times</em>, Virgin already earns <a href="">around £200 million a year by running more than 100 NHS services nationwide, including GP surgeries.</a></p> <p>As patients we will no longer necessarily come first: <strong>how can we feel confident that our doctor is putting us first when he or she is a for-profit company employee</strong>?</p> <p><strong>It is clear that the government is manufacturing a crisis</strong>, reducing the level of services and their quality, and shaking public confidence in the NHS. But claims that we can no longer afford the NHS are untrue. The NHS is not over budget. Last year the NHS budget was under spent and <a href="">£2 billion was returned to the Treasury</a>.</p> <p>This year it s a similar story. Headline stories about hospital and other health service deficits only mean that resources are unfairly distributed not that the NHS is unaffordable overall.</p> <p>The answer of course is political not financial. <strong>A new Act is needed to reinstate the NHS</strong>. These changes are the culmination of a transition from public to private responsibility as market dogma has penetrated, only to abolish, an institution that has defined us in our own eyes and internationally.</p> <p>By removing the mandate on government to provide a health service, the Health and Social Care Act 2012 is <strong>the crowning achievement of the architects of this long recessional from universality</strong>. Our response must be political too.</p><p>&nbsp;</p><p><em>&nbsp;</em></p> </div><div class="field field-country"> <div class="field-label"> Country or region:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> UK </div> </div> </div> <div class="field field-topics"> <div class="field-label">Topics:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Civil society </div> <div class="field-item even"> Democracy and government </div> </div> </div> ourNHS uk ourNHS UK Civil society Democracy and government David Price Allyson Pollock Thu, 28 Mar 2013 10:46:14 +0000 Allyson Pollock and David Price 71872 at Briefing paper - the NHS reinstatement bill <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>An explanation of what David Owen's new bill is trying to achieve and why it is needed</p> </div> </div> </div> <p><strong>&nbsp;The Abolition of the democratic and legal basis for the NHS in England</strong></p><p>The democratic and legal basis for the NHS in England was abolished by the Health and Social Care Act 2012. The impact of this fundamental change is already being felt, ahead of the shift to the new market system in April 2013.&nbsp;&nbsp; </p><p>The Act ended the Secretary of State’s duty to secure or provide health services throughout the country, a duty that had been in force since 1948. </p> <p>A minister may only be held to account legally for services that he or she is responsible for by law. In future, if we can’t get the health care we need, ministers won’t have to worry about being taken to court on this count, and there will be no Primary Care Trust to put pressure on.&nbsp; This means fewer rights for people in England to get the health care we need – at a time of unprecedented cuts and closures.</p> <p>The Act breaks up the universal system that has served us for over sixty years, and reduces the NHS to a stream of taxpayer funds and a logo for the use of a range of public and corporate providers of services. </p> <p>A House of Lords’ bill published this week will reinstate the Secretary of State’s legal duty to provide the NHS in England and the right of all of us in England to comprehensive and integrated health care. </p> <p>By restoring the legal and democratic basis, the new National Health Service (Amended Duties and Powers) Bill will ensure basic questions about citizens’ rights will continue to be determined democratically, as they should be. </p> <p>This briefing explains what the government is doing and why an urgent bill to reinstate the NHS in England is required<em>.</em><em>&nbsp;</em></p> <p><strong>What does the government’s Act mean for me? </strong></p> <p><strong>Cutting free NHS services</strong> </p> <p>When the 2012 Act is implemented, the government will no longer be responsible for providing for our health care needs free of charge. The system of health care which has served all people throughout England for over sixty years is being dismantled and broken up. Instead a range of bodies, including for-profit companies, will decide which services will be freely available and who will receive them. </p> <p>Currently many NHS services are being transferred to local authorities. They can bring in commercial companies to run them and the 2012 Act provides new charging powers. During the passage of the Health and Social Care Bill last year these services included<a href="#_edn1">[1]</a>:</p> <ul><li>immunization, cancer and cardiovascular screening</li><li>mental health care</li><li>dental public health</li><li>public health </li><li>sexual health services</li><li>management of drug and alcohol addiction</li><li>emergency planning and health protection service</li><li>child health services.</li></ul><ul><li> </li></ul><p>Concerns were repeatedly raised during the passage of the Bill that some services would no longer required by law to be provided free of charge. These services included:&nbsp; <a href="#_edn2">[2]</a></p> <ul><li>Services and facilities for pregnant women, women who are breast-feeding </li><li>Services for both younger and older children</li><li>Services for the prevention of illness</li><li>Care of persons suffering from illness and their after-care</li><li>Ambulance services</li><li>Services for people with mental illness</li><li>Dental public health services</li><li>Sexual health services</li></ul> <p><strong>Putting commercial companies in control</strong></p> <p>The Act also promotes more marketisation. More and more NHS services are being put out to tender to for-profit companies and taxpayer funds are being given to commercial corporations whilst publicly run health facilities are closed down.</p> <p>As the 2012 Act is being implemented, corporations will have more say in determining our entitlement to free health services. In future, no single organisation will be responsible in our area for ensuring all our care.&nbsp; And it will no longer be clear who should be held accountable when things go wrong. </p> <p>Our relationship with our doctor will change when for-profit companies run more services. As a patient we will no longer necessarily come first: how can we feel confident that our doctor is putting us first when he or she is a for-profit company employee? </p> <p>Privatisation and marketization has increased in advance of the Act.</p> <p>Some services, including those for the most vulnerable people in society, were last year contracted out to for-profit companies such as Virgin and Serco, which have little or no experience in delivering care. These include services for children with mental health problems and physical disabilities in Devon<a href="#_edn3">[3]</a>, and community nursing and health visitor services in Surrey<a href="#_edn4">[4]</a> and Suffolk<a href="#_edn5">[5]</a>.</p> <p>Many NHS hospitals are owned and operated under the expensive private finance initiative, creating serious financial problems for them and putting neighbouring hospitals and services at risk. For-profit companies and investors now control GP practices and other local health services. According to the Financial Times, Virgin already earns around £200 million a year by running more than 100 NHS services nationwide, including GP surgeries.<a href="#_edn6">[6]</a> A private company registered in the Virgin Islands now manages the local hospital in Huntingdon, Hinchingbrooke NHS Trust.</p> <p><strong>The government is manufacturing a financial crisis in the NHS. </strong></p> <p>It is clear that the government is manufacturing a crisis, reducing the level of services and their quality, and shaking public confidence in the NHS. We are being encouraged to accept the principle that we will in future have to pay privately for services that were once free.</p> <p>But claims that we can no longer afford the NHS are untrue. </p> <p>The NHS is not over budget. Last year the NHS budget was underspent and £2 billion was returned to the Treasury.<a href="#_edn7">[7]</a> Headline stories about hospital and other health service deficits only mean that resources are unfairly distributed not that the NHS is unaffordable overall.</p> <p>Government claims that it is protecting the NHS budget are also untrue.</p> <p>According to the official watchdog, the Statistics Authority: “expenditure on the NHS in real terms was lower in 2011-12 than it was in 2009-10.”<a href="#_edn8">[8]</a></p> <p>The NHS is being run as if it is in a financial crisis but this crisis is of the government’s making. Current plans for cutting NHS budgets, hospital beds and sacking thousands of vital NHS staff are based on documents drawn up by management consultancy firms including the US company, McKinsey &amp; Co. The policy will lead to closure and hollowing out of public services and the creation of opportunities for an expanded market for private provision and the introduction of user charges. </p> <p>The policy is fuelling cuts, closures and mergers on a scale that is unparalleled. There is no evidence to support change on this scale nor the unfair distribution of funds<a href="#_edn9">[9]</a>.<strong> </strong></p> <p><strong>Cuts and closures</strong></p> <ul><li>In North West London the government plans to cut 25% of beds, and throughout London at least 7 accident and emergency departments will close<a href="#_edn10">[10]</a>, with further departments under threat. Up to 5600 jobs in North West London will be lost by 2015<a href="#_edn11">[11]</a>.&nbsp; Barnet and Chase Farm Hospitals NHS Trust is cutting 208 posts.<a href="#_edn12">[12]</a></li><li>In Merseyside, 4000 NHS jobs will go by 2014<a href="#_edn13">[13]</a></li><li>In South Yorkshire, Rotherham Hospital is set to lose 750 staff by 2015<a href="#_edn14">[14]</a></li><li>In West Suffolk, Serco is planning to cut 137 Community Healthcare jobs.<a href="#_edn15">[15]</a></li><li>In Devon and Exeter, the Royal Devon and Exeter NHS Foundation Trust plans to cut 1115 full-time equivalent posts between 2011 and 2014.<a href="#_edn16">[16]</a></li><li>In Greater Manchester, there are plans to downgrade Trafford General Hospital’s A&amp;E to urgent care and cuts to intensive care, acute surgery and children’s services. <a href="#_edn17">[17]</a> Maternity services have already closed.<a href="#_edn18">[18]</a> Salford Royal NHS Foundation Trust plans to cut 750 full-time posts by 2013. <a href="#_edn19">[19]</a> Bolton NHS trust is making 500 redundancies.<a href="#_edn20">[20]</a></li><li>In Warwickshire, the George Eliot Hospital NHS Trust plans to cut the equivalent of 257 full-time staff between 2010 and 2014.<a href="#_edn21">[21]</a></li><li>In Cornwall, Royal Hospital Truro proposed to cut 400 jobs in 2011.<a href="#_edn22">[22]</a></li><li>In Portsmouth, Queen Alexandra Hospital cut 700 jobs and shut 3 wards in 2011<a href="#_edn23">[23]</a>. </li><li>Across England, twenty four out of thirty NHS Direct call centres will close<a href="#_edn24">[24]</a></li><li>6000 nursing posts have been cut since the coalition came to power in 2010.<a href="#_edn25">[25]</a></li></ul> <table border="0" cellspacing="0" cellpadding="0" width="525"> <tr> <td width="533" valign="top"> </td> </tr> </table> <p><strong>Mergers</strong></p> <p>Hospital mergers reduce services and increase waiting times and travel distances. </p> <ul><li>Merger with North Tees was followed by closure of A &amp; E in Hartlepool in August 2011<a href="#_edn26">[26]</a> </li><li>Merger of&nbsp; South London trust is followed by recommendation of closure of &nbsp;Lewisham hospital A&amp;E. <a href="#_edn27">[27]</a></li><li>Merger of Queen Mary’s Sidcup NHS Trust (QMS), Queen Elizabeth Hospital NHS Trust (QEH) and Bromley Hospitals NHS Trust (BHT) to create a single hospital on several sites in 2009 was followed by closure of Queen Mary’s A&amp;E and labour unit in 2010.<a href="#_edn28">[28]</a></li><li>Merger of Norfolk and Waveney and Suffolk mental health trusts was followed by cuts in beds for acute mental illness and community mental health teams<a href="#_edn29">[29]</a></li><li>Barnet and Chase Farm Hospitals NHS trust currently plans a merger which is likely to result in closure of A&amp;E, maternity and paediatric services <a href="#_edn30">[30]</a>.</li><li>Merger resulted in closure of Trafford General Maternity Unit in 2010<a href="#_edn31">[31]</a> and A&amp;E is threatened.<a href="#_edn32">[32]</a></li><li>Merger with Blackburn Hyndburn and Ribble Valley (BHRV) NHS Trust in 2003 was followed by closure of Burnley A&amp;E in 2008<a href="#_edn33">[33]</a> and the paediatric inpatient ward in 2010<a href="#_edn34">[34]</a>.</li><li>Merger resulted in closure of Rochdale Infirmary, Greater Manchester A&amp;E in 2011<a href="#_edn35">[35]</a>.</li></ul> <p><strong>Why a Bill is needed to reverse the worst aspects of the Act?</strong> </p> <p>The Health and Social Care Act 2012 must be changed because it removes the democratic and legal basis of the NHS at a time when services are being cut and reconfigured on an unprecedented scale. </p> <p>The NHS was created in 1948 by a law requiring the secretary of state to fund and provide all medical, dental and nursing care to the whole population on an equitable basis throughout the country. &nbsp;This duty has been abolished. </p> <p>The government has no mandate for this Act.&nbsp; We did not vote for the abolition of our NHS. Neither was it a part of the coalition agreement. Unlike England, citizens of Scotland, Wales, and Northern Ireland will continue to have a NHS. </p> <p><strong>The purpose and limitations of the urgent Bill</strong></p> <p>The proposed legislation restores the legal and democratic basis of the NHS and the citizens’ rights ultimately to hold the Secretary of State to account.&nbsp; It will restore the Secretary of State’s duty to provide the NHS in England and gives him or her ministerial powers of direction and planning in order that the duty can be properly discharged. </p> <p>Specifically, the Bill will:</p> <ul><li>reinstate the secretary of state’s duty to provide health services that was formerly contained within sections 1 and 3 of the NHS Act 2006;</li><li>subject all NHS bodies and bodies providing services for the NHS to ministerial direction;</li><li>repeal the duty of autonomy and restore sufficient ministerial control over provision consistent with the secretary of state’s overarching duty to provide health services to the whole of England; and</li><li>give Monitor an objective, so that its purpose is to help deliver the NHS. &nbsp;</li></ul> <p class="ColorfulList-Accent11CxSpMiddle">The Bill will not require further reorganization when it is passed.</p> <p><strong>Allyson&nbsp; M Pollock</strong> (Professor of Public health research and policy, </p> <p><strong>David Price</strong> (Senior Research Fellow)</p> <p>Global health, policy and innovation unit</p><p>Centre for Primary Care and Public Health </p><p>Queen Mary, University of London</p><p>&nbsp;</p><p class="ColorfulList-Accent11">58 Turner St, London E1 2AB and R</p><p>&nbsp;</p> <hr size="1" /> <p><a href="#_ednref1">[1]</a> Pollock AM, Price, DP, Roderick, P.&nbsp; How the Health and Social care Bill2011 would end entitlement to comprehensive health care in England, January 26, 2012 DOI:10.1016/S0140- 6736(12)60119-6 </p><p><a href="#_ednref2">[2]</a> Pollock AM, Price D, Roderick P. Health an social care Bill 2011: a legal basis for charging and providing fewer health services to people in England.&nbsp; BMJ 2012;344:1729- 82</p> <p><a href="#_ednref3">[3]</a> <a href=""></a></p> <p><a href="#_ednref4">[4]</a> <a href=""></a></p> <p><a href="#_ednref5">[5]</a> <a href=""></a></p> <p><a href="#_ednref6">[6]</a> <a href=""></a></p> <p><a href="#_ednref7">[7]</a> Department of Health: Securing the future financial sustainability of the NHS, Sixteenth Report of Session 2012–13, House of Commons, Committee of Public Accounts<em> </em><a href=""></a></p> <p><a href="#_ednref8">[8]</a> Andrew Dilnot, (Chair of the UK Statistics Authority) Letter to Right Hon Jeremy Hunt MP, dated 4th December 2012, <a href=""></a></p> <p class="ColorfulList-Accent11"><a href="#_ednref9">[9]</a> ‘Can governments do it better? Merger mania and hospital outcomes in the English NHS’, M Gaynor, M Laudicella and C Propper, CMPO working paper 12/281 <a href=""></a></p> <p><a href="#_ednref10">[10]</a> <a href=""></a></p> <p><a href="#_ednref11">[11]</a> <a href=""></a> Tuesday 23rd October 2012</p> <p><a href="#_ednref12">[12]</a> <a href=";headline=Alarm%20over%20job%20cuts%20at%20hospital">;headline=Alarm%20over%20job%20cuts%20at%20hospital</a></p> <p><a href="#_ednref13">[13]</a> <a href=""></a></p> <p><a href="#_ednref14">[14]</a> <a href=""></a></p> <p><a href="#_ednref15">[15]</a> <a href=""></a></p> <p><a href="#_ednref16">[16]</a> <a href=""></a></p> <p><a href="#_ednref17">[17]</a> <a href=""></a></p> <p><a href="#_ednref18">[18]</a> <a href=""></a></p> <p><a href="#_ednref19">[19]</a> <a href=""></a></p> <p><a href="#_ednref20">[20]</a> <a href=""></a></p> <p><a href="#_ednref21">[21]</a> <a href=""></a></p> <p><a href="#_ednref22">[22]</a> <a href=""></a></p> <p><a href="#_ednref23">[23]</a> <a href=""></a></p> <p><a href="#_ednref24">[24]</a> <a href=""></a></p> <p><a href="#_ednref25">[25]</a> <a href=""></a></p> <p><a href="#_ednref26">[26]</a> <a href=""></a></p> <p><a href="#_ednref27">[27]</a> <a href=""></a></p> <p><a href="#_ednref28">[28]</a> <a href=""></a></p> <p><a href="#_ednref29">[29]</a><a href=""></a></p> <p><a href="#_ednref30">[30]</a> <a href=""></a></p> <p><a href="#_ednref31">[31]</a> <a href=""></a></p> <p><a href="#_ednref32">[32]</a> <a href=""></a></p> <p><a href="#_ednref33">[33]</a> <a href=""></a></p> <p><a href="#_ednref34">[34]</a><a href=""></a></p> <p><a href="#_ednref35">[35]</a> <a href=""></a></p><fieldset class="fieldgroup group-sideboxs"><legend>Sideboxes</legend><div class="field field-related-stories"> <div class="field-label">Related stories:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> <a href="/ournhs/david-owen/bill-to-re-instate-nhs">A bill to re-instate the NHS?</a> </div> </div> </div> </fieldset> ourNHS uk ourNHS Re-instatement bill Rationing Cuts Charging and insurance Commissioning Private healthcare Allyson Pollock David Price Louisa Harding-Edgar Wed, 30 Jan 2013 09:38:33 +0000 Allyson Pollock, David Price and Louisa Harding-Edgar 70643 at ‘Commercial confidentiality’ trumps public right to know in England’s new health market <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>In the new competitive market for healthcare created by the Health and Social Care Bill it will become increasingly difficult to know what exactly is being done with public money.&nbsp;</p> </div> </div> </div> <p><em>UPDATE: </em><a href=""><em>Seven out of ten hospital doctors voted to reject the NHS</em></a><em> shakeup in a poll released by the Royal College of Physicians yesterday.</em></p><p>In the new competitive market for healthcare created by the Health and Social Care Bill it will become increasingly difficult to know what exactly is being done with public money.</p> <p>Claims of <em>“commercial confidentiality”</em> are already being used to prevent public scrutiny of the first contract with a private company to run an NHS hospital. In November 2011, the Government announced that <a href="">Circle Healthcare</a> would be contracted to run Hinchingbrooke hospital, the first NHS hospital to have its management taken over by a private business. </p> <p>Circle Healthcare is part owned by its employees. Its chief executive is former Goldman Sachs executive Ali Parsa.&nbsp; Circle began its management of the hospital, which will last for ten years, on 1st February 2012. The Hinchingbrooke contract was signed after a thirteen-month procurement managed by NHS Midlands and East, and a subsequent approval process from the Department of Health. Circle was selected from nineteen initial potential bidders from the public and independent sectors.</p> <p>But it is not possible for the public to make a fully informed judgement about the contract, because both the Treasury and Department of Health have refused to release key information, despite requests by academic researchers at Queen Mary, University of London under the Freedom of Information Act (FoI).&nbsp;Both the Treasury and the Department of Health have said that a <em>“redacted”</em> version of the Full Business Case for the contract will be published at some unspecified future date, but have refused to release information on the financial models and methodology on which the contract is based. </p> <p>The Government is claiming exemption from the FoI Act under Section 43 of the Act, which deals with commercially sensitive information. The Treasury letter setting out the reasons for this refusal says that <em>“the commercial interests of the NHS and/or Circle”</em> are more important in this case than the public interest in transparency and accountability in the use of public funds. </p> <p>Ensuring that commercial confidentiality was not used as a reason to prevent public scrutiny of NHS contracts under the legislation was a key demand of the Liberal Democrat Spring Conference in 2011. And the February 2012 letter on amendments to the Bill from Nick Clegg and Shirley Williams stated that:&nbsp;“no one should be allowed to spend public money without telling us how they are going to use it. That is why we have insisted that decisions about patient services and taxpayers' money must be made in an open, transparent and accountable way.”</p> <p>In a letter to all peers dated 22nd December 2011 Earl Howe promised regulations covering healthcare commissioners would to ensure <em>“transparency in the commissioning process”</em>.&nbsp; However, he also wrote that these regulations would be based on the existing Principles and Rules for Co-operation and Competition in the NHS<em> “which we will retain to ensure continuity”</em>. These rules cover the Hinchingbrooke hospital contract. </p> <p>It is always crucial to ensure proper accountability in the health system. But it will be even more important if the sprawling Health and Social Care Bill makes it to the statute book. In future healthcare will be arranged through tens of thousands of commercial contracts. The Bill as it stands does not ensure transparency and accountability in the use of public money. Ministers, civil servants, healthcare businesses and managers will be able to claim exemption from Freedom of Information legislation on grounds of commercial confidentiality. It would be outrageous if the Health Bill became law without this loophole being properly plugged.</p> <p>Crossbencher Lord David Owen has agreed to deliver the Save Our NHS petition organised by 38 Degrees to the House of Lords before the Third Reading of the Health Bill on Monday 19 March. It will be carried into the House of Lords chamber just before the debate starts. </p> <p>The petition will remind Lords of widespread public concern about the damage the Health Bill will do to the NHS. There is still time to <a href="">sign it</a>.</p> <p><strong>&nbsp;</strong></p> <p><strong>Chronology of FoI requests</strong></p> <p>10th November 2011&nbsp;<strong>Request made in writing for copy of contract by Professor Allyson Pollock under Freedom of Information Act</strong>.</p> <p>3rd January 2012&nbsp;<strong>Email sent by Dr. Vanessa Jessop requesting copy of contract to East of England NHS</strong></p> <p>17th January 2012&nbsp;<strong>Response from FOI at NHS Midlands and East</strong></p> <p>Please find below the link to the franchise agreement for Hinchingbrooke Hospital Health Care NHS Trust.</p> <p></p> <p>30th January 2012&nbsp;<strong>Complaint sent by email to requesting internal review and additional information:</strong></p> <p>Please could you send the FBC, the contract and all the appendixes and addendum including financial models that underpin each document.</p> <p><strong>Emails sent to DH, Treasury and SHA requesting the same information.</strong></p> <p>Necessary to request internal review before complaint to FOI Commissioner can be made:</p> <p></p> <p>22nd February 2012&nbsp;<strong>Response from DH received</strong></p> <p>Disclosure of financial methods and methodology refused. Exemption claimed under S.43 of FOI.&nbsp; </p> <p>Disclosure of Full Business Case refused under S.22.</p> <p>23rd February 2012&nbsp;<strong>Response from Treasury received</strong></p> <p>Disclosure of financial methods and methodology refused. Exemption claimed under S.43. A “redacted” Full Business Case to be published at an unspecified future date. Key quote: <em>“S 43 is a qualified exemption … we recognise that there is a public interest in transparency in the accountability of public funds … There is also an interest in knowing that the Government is achieving value for public money and that commercial activities are conducted in an open and honest way... However there is also a strong case for non-disclosure as we believe that release would be likely to prejudice the commercial interests of the NHS and/or Circle.”</em></p> <p><strong>&nbsp;</strong></p><div class="field field-topics"> <div class="field-label">Topics:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Civil society </div> <div class="field-item even"> Democracy and government </div> </div> </div> Shinealight uk ShineALight Civil society Democracy and government Secrecy Privatisation Circle Shine A Light Allyson Pollock Sat, 17 Mar 2012 08:30:09 +0000 Allyson Pollock 64774 at The end of the NHS as we know it <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>"How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England" republished from <em>The Lancet</em> with thanks.</p> </div> </div> </div> <p>Republished from <em>The Lancet</em> with thanks. </p><p>The National Health Service (NHS) in England has been a leading international model of tax-financed, universal health care. Legal analysis shows that the Health and Social Care Bill currently making its way through the UK Parliament<a href="#1">[1]</a> would abolish that model<a href="#2">[2]</a> and pave the way for the introduction of a US-style health system by eroding entitlement to equality of health-care provision. The Bill severs the duty of the Secretary of State for Health to secure comprehensive health care throughout England and introduces competitive markets and structures consistent with greater inequality of provision, mixed funding, and widespread provision by private health corporations. The Bill has had a turbulent passage. Unusually, the legislative process was suspended for more than 2 months in 2011 because of the weight of public concern.<a href="#3">[3]</a> It was recommitted to Parliament largely unaltered after a “listening exercise”. These and more recent amendments to the Bill do not sufficiently address major concerns that continue to be raised by Peers and a Constitution Committee of the House of Lords,<a href="#4">[4,5]</a> where the Bill now faces one of its last parliamentary hurdles before becoming law.<!--break--></p> <p><div class="pullquote-right"> <em><strong>Red lines to protect the NHS</strong></em> <br />1. The Secretary of State must have the duty to secure provision of comprehensive and equitable health care for the whole of the population of England, taking action whenever there are problems <br />2. CCGs, operating on behalf of the Secretary of State, must make sure that comprehensive and equitable health care is available for everyone and be responsible for all residents living in single geographically defined areas that are contiguous, without being able to pick and choose patients. <br />3. Nothing must be done that undermines the ability of the Secretary of State to fulfil the duty to secure provision of comprehensive and equitable health care, by bringing more of the NHS within the scope of EU competition law so that, in particular: <ul><li>There must be no increase in the commercial contracting of health services;</li> <li>The current authorisation system for central regulation of Foundation Trusts must be retained; </li><li>Statutory functions of CCGs must be carried out by NHS staff, with CCG finances being used solely for the benefit of patients;</li> <li>Statutory and enforceable codes of conduct must be laid down for all NHS bodies, underpinned by sanctions that are rigorously policed;</li> <li>Information about commercial contracting, including the planning, procurement, financing, and monitoring, must be available as a matter of course.</li></ul> <small>CCGs=Clinical Commissioning Groups.</small> </div> </p><p>Fundamental to the Bill are provisions that transform a mandatory system into a discretionary one with structures that permit the introduction of charging for services that are currently free under the NHS, as well as a system in which much delivery would be privatised. Under the current statutory framework the Government has a legal duty to secure comprehensive health care, whereas, under the new system, substantial discretionary powers will instead be extended to commissioners and providers of care. These measures will increase inequalities of provision.</p> <p>Clauses 1 and 12 of the Bill will dismantle key sections of the 1946 founding legislation of the NHS by repealing the unifying duty from which all other legislative powers and functions flow.<a href="#6">[6]</a> This unifying duty is currently laid down in Sections 1 and 3 of the National Health Service Act 2006. It requires the Government to promote a comprehensive health service by providing or securing the provision throughout England of a list of specified NHS services and hospital accommodation in ways that meet all reasonable requirements. Accordingly, since 1948, most NHS hospital and community-based provision has its own facilities and NHS staff. The whole system has been publicly administered and funded on the basis of contiguous geographical areas by bodies, now called primary care trusts (PCTs), that act on behalf of the Secretary of State and have responsibility for the health-care needs of everyone in their area. Experiments with internal and external markets since 1990 have taken place within this overarching geographical framework.</p> <p>The Bill creates two new bodies with responsibility for managing care: an NHS Commissioning Board and Clinical Commissioning Groups (CCGs), the number of which remain unclear. PCTs will be abolished and not replaced. Powers currently exercised by the Secretary of State for Health will be transferred to each CCG, which, in contrast to PCTs, will act in place of, and not on behalf of, the minister. The NHS Commissioning Board will exercise its functions at a distance from the Secretary of State and have oversight of CCGs. These changes will repeal the minister’s core duty to provide or secure provision of specified health services.&nbsp;</p> <p>Clause 12 of the Health and Social Care Bill repeals the Secretary of State’s “duty to provide” specific services. Instead, a “duty to arrange” provision is imposed on each of the many CCGs that will also have transferred to them the power to determine what care is necessary to meet all reasonable requirements. However, CCGs will not have the duty to promote a comprehensive free health service. Amendments suggested by the Government in a letter to Peers from the responsible minister dated Jan 12, 2012, do not restore the duty.<a href="#7">[7]</a> Thus, the link between the duty to promote comprehensive care and the duty to provide would be severed.&nbsp;</p> <p>Although the Government has said that its intention is to “reinforce” the overarching duty to promote a comprehensive health service,<a href="#8">[8]</a> the creation of bodies that are independent of the Secretary of State for Health to support a lesser duty fundamentally affects the minister’s duty. This is because the test of whether the Secretary of State is discharging his or her duty to promote a comprehensive health service will no longer depend on whether a comprehensive service is actually provided.</p> <p>As well as transferring powers from the Secretary of State to other bodies, the Bill leaves each CCG free to choose the patients for whom they have responsibility. Unlike PCTs, CCGs will not be responsible for all residents within contiguous geographical areas. CCGs select patients, initially assembling their patient populations on the basis of general practitioners’ (GPs) lists; they will not have to cover everyone in a geographical area but only “persons for whom it [the CCG] has responsibility”. Nor will they be required to arrange for the provision of all the services that are currently part of the comprehensive health system. For example, accident and emergency services are not an explicit CCG responsibility under these proposals. Only a new category “of services or facilities for emergency care” will have to be provided for people in a CCG’s area, which need not consist of adjoining or indeed whole electoral districts, as is the case with PCTs.</p> <p>Another organisation, known as Monitor and with the functions of a regulator, is independent of the Secretary of State for Health, and will have oversight of providers (public and private) in the new system. However, it will not have a duty to promote a comprehensive service—a crucial consideration given that its decisions about the extent of competition will affect the financial viability of local services. In a parallel move, NHS hospitals that currently get most of their funding from NHS sources will be free to obtain almost half their income from private patients.</p> <p>Although there are provisions in the Bill giving the Secretary of State for Health power to regulate the new system through secondary rather than primary legislation, that power is limited by a new clause (Clause 4), under which the minister has a duty to observe the autonomy of commissioners and providers. The autonomy clause means that commercial providers can bring legal challenges against a minister who chooses to curtail their discretion. Furthermore, the adoption of compulsory market competition will bring more NHS activity under the jurisdiction of EU competition law. Competition law is designed to limit government powers of intervention and will provide a further check on secondary regulation.</p> <p>These changes will have substantial legal consequences. First, the duty to provide a national health service throughout England would be lost if the Bill became law.<a href="#9">[9]</a> It would be replaced by a duty on an unknown number of CCGs, not GPs, to arrange provision as they see fit for various sections of the population for which they are separately responsible. Second, CCGs would not be bound by the “duty to continue to promote a comprehensive free health service” when exercising their functions. Under present law, according to a judgment of the Court of Appeal, the Secretary of State “has the duty to continue to promote a comprehensive free health service and he must never, in making a decision [about services provided], disregard that duty”.<a href="#10">[10]</a> Third, the Secretary of State’s accountability to Parliament for the provision of services to patients in the new NHS will be diminished.<a href="#4">[4,</a><a href="#11">11]</a></p> <p>At the same time, a new parallel system of public health services will be established at the local level. Under this system, the provision of a range of public health services will be assigned to local authorities, including immunisation, screening, mental health, dental health, children’s services, sexual health, drug and alcohol services, and health protection programmes. However, neither services nor funding have been defined.<a href="#12">[12]</a> Moreover, in this new system local authorities will have considerable discretion to define and decide what services are provided and how. As with the social services they provide, these services may be chargeable.</p> <p>All these factors will increase inequality in service access, provision, and uptake. The abolition of PCTs and loss of overall political control will impair, or take away altogether, current information systems used to monitor inequalities at area level. The new structures for CCGs and public health create such a multiplicity of denominators, resource flows, populations, and fragmented responsibilities for care and data that systematic inequalities will cease to be identifiable and no body will have overall responsibility for an area. Furthermore, the loss of area-based population responsibilities has serious implications for the stability and accuracy of measurement of needs and equity of resource allocation and service provision. Loss of geographical population data and area-based structures and responsibilities will impair, or take away altogether, the capacity to plan health services by monitoring needs, access, service use, and health outcomes.&nbsp;</p> <p>The Government has not disclosed the radical nature of this reform. The Leader of the House of Lords, Earl Howe, told the Lords that the Bill reinforces and does not “dilute the Secretary of State’s overarching duty…Let me be clear: the Bill’s provisions would in no way dilute the Secretary of State’s overarching duty. Indeed, they are intended further to reinforce the promotion of a comprehensive health service rather than to undermine it.”<a href="#7">[7]</a> Legal analysis of the Bill shows this is not the case. Recent amendments raised for consideration in a letter of Jan 12, 2012, from Earl Howe to Peers do not substantially change the situation.<a href="#7">[7]</a></p> <p>In the USA, opposition to health reforms under both the Clinton and Obama administrations is articulated as erosion of personal freedom by increasing government powers.<a href="#13">[13]</a> Conversely, pro-market reforms of universal health systems in Europe are often justified on the grounds that they increase personal freedom by transferring powers from government to non-governmental or commercial bodies and by increasing choice. Citizens’ rights in democracies are underpinned not just by limitations on government powers but also by legal duties imposed on governments, such as those that guarantee citizens access to health care. The Bill would withdraw this legal underpinning.<a href="#14">[14]</a> As the Bill enters its final critical stages it is crucial that Peers observe three red lines for the NHS (panel)<a href="#15">[15]</a> and are fully aware of the key parts of the legislation that would abolish core NHS functions, if they are to safeguard the NHS for future generations.&nbsp;</p> <p><em>*Allyson M Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee, Lucy Reynolds</em></p> <p>Centre for Primary Care and Public Health, Queen Mary, University of London, London E1 4NS, UK (AMP, DP); 101 Weavers Way, London, UK (PR); 5 Hobson Road, Oxford, UK (TT); Inner North West London Primary Care Trusts, London, UK (DM); and European Centre on Health of Societies in Transition, London School of Hygiene and Tropical Medicine, London, UK (MM, LR)<br /></p> <p>PR is a London-based public interest lawyer who has supported 38 Degrees on an unpaid basis. TT is a non-practising barrister and formerly Head of Legal Services, Vale of White Horse District Council. The other authors declare that they have no conflicts of interest.</p> <p><strong><em>"How the Health and Social Care Bill 2011 would end entitlement to comprehensive health care in England" is republished from <em>The Lancet</em> with thanks. See also: Clare Sambrook, <a href="">'The truth about health "reform": it's the demolition of the NHS'</a></em></strong></p> <p><strong>References:</strong></p> <p><a name="1"></a>1. House of Lords. Health and Social Care Bill 2011. HL Bill 92. ,<a href=""></a> (accessed Jan 20, 2012).</p> <p><a name="2"></a>2 Pollock AM, Price D. How the Secretary of State for Health proposes to abolish the NHS in England. <em>BMJ</em> 2011; <strong>342:</strong> 800–03.&nbsp;</p> <p><a name="3"></a>3. NHS Futures Forum. Summary Report on proposed changes to the NHS. London: London School of Hygiene and Tropical Medicine, 2011.</p> <p><a name="4"></a>4. House of Lords Select Committee on the Constitution. Health and Social Care Bill. HL Paper 197, Sept 30, 2011. London: The Stationery Office Ltd, 2011. <a href=""></a> (accessed Jan 20, 2012).&nbsp;</p> <p><a name="5"></a>5. House of Lords Select Committee on the Constitution. Health and Social Care Bill: Follow-up. HL Paper 240, Dec 20, 2011. London: The Stationery Office Ltd, 2011. <a href=""></a> (accessed Jan 20, 2012).</p> <p><a name="6"></a>6. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill, Briefing on Clause 1. 2011. <a href=" "></a> (accessed Jan 17, 2012).</p> <p><a name="7"></a>7. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill, Briefing note 12, Earl Howe’s response to the Constitution Committee’s follow-up report and his letter dated Jan 12, 2012. <a href=""></a> (accessed Jan 17, 2012).</p> <p><a name="8"></a>8. House of Lords Debate. Nov 14, 2011 column 494. Hansard. <a href=""></a> (accessed Jan 20, 2011).</p> <p><a name="9"></a>9. 38 Degrees. NHS expert legal advice. <a href=""></a> (accessed Jan 20, 2012).</p> <p><a name="10"></a>10. Coughlan &amp; Ors, R (on the application of) v North &amp; East Devon Health Authority [1999] EWCA Civ 1871 (July 16, 1999). <a href=""></a> (accessed Jan 20, 2012).</p> <p><a name="11"></a>11. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill 2011, House of Lords Committee Stage, Briefing Note 2, on Clause 1 for day 1 Oct 25, 2011 in the light of evidence from Professor Malcolm Grant. <a href=""> </a>(accessed Jan 24, 2012).&nbsp;</p> <p><a name="12"></a>12. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill 2011, House of Lords Committee stage, Briefing Note 7, Clause 8 (Amendments 60B–75A) for Monday Nov 14, 2011. <a href=""></a>(accessed Jan 20, 2012).</p> <p><a name="13"></a>13. Starfield B. The Obama presidency: what may happen, what needs to happen in health policies in the USA. <em>J Epidemiol Community Health</em> 2009; <strong>63:</strong> 265–66.</p> <p><a name="14"></a>14. Pollock AM, Price D, Roderick P, Treuherz T. Health and Social Care Bill 2011, House of Lords Committee stage, Briefing Note 6 Clause 10. <a href=" "></a>(accessed Jan 20, 2012).</p> <p><a name="15"></a>15. Health and Social Care Bill 2011. House of Lords Report Stage. Briefing Note 10: Red Lines for Peers on the NHS Bill. Jan 9, 2011. <a href=""></a> (accessed Jan 20, 2012).</p><p></p><div class="field field-country"> <div class="field-label"> Country or region:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> UK </div> </div> </div> <div class="field field-topics"> <div class="field-label">Topics:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Civil society </div> <div class="field-item even"> Democracy and government </div> </div> </div> uk uk UK Civil society Democracy and government OurKingdom debates the NHS Lucy Reynolds Martin McKee David Price David McCoy Peter Roderick Tim Treuherz Allyson Pollock Fri, 27 Jan 2012 13:54:00 +0000 Allyson Pollock, David Price, Peter Roderick, Tim Treuherz, David McCoy, Martin McKee and Lucy Reynolds 63885 at The abolition of the NHS. That’s what is happening. <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> <p>In unscripted remarks, the UK Prime Minister revealed his true agenda: he wants to turn our universal health care system into “a fantastic business”. Not patient choice but choice of patient will be the order of the day.</p> </div> </div> </div> <p>In a speech on exports and growth on 10th November 2011, David Cameron went “<span><a class="western" href="">off-script</a></span>” and revealed his government’s true agenda for the NHS. Standing in front of a Union Jack banner and the slogan “START UP BRITAIN” the Prime Minister told his audience of small and medium enterprise people at the BFI on London’s South Bank: “We have a growth review, led by the Chancellor and the business secretary, which ensures that every minister has to come to the table with proposals to cut regulation in their departments and come up with ways of helping business in their sector, helping them to grow.” Then he said: “From the Health Secretary, I don’t just want to know about waiting times. I want to know how we drive the NHS to be a fantastic business for Britain.”</p> <p>He really said that. It’s <span><a class="western" href="">here</a></span> on video: “I want to know how we drive the NHS to be a fantastic business for Britain.”</p><p></p><p>That same week <span><a class="western" href="">Hinchingbrooke Hospital became the first NHS Hospital to be franchised</a></span> to a large for profit health care company —&nbsp;Circle.</p><p>The NHS is already big business and some of the costs are there for everyone to see.&nbsp; (Much is hidden). The NHS is haemorrhaging public funds to hundreds of companies through a range of services, legal, accountancy, catering cleaning, PFI and health care.</p> <p>For the last two decades government policy has been to divert billions of pounds of NHS spending to for-profit corporations, including the multi billion pound PFI debt programme. Inflation-proofed PFI payments absorb around 15 per cent&nbsp;of hospitals’ budgets and the figure is rising. No wonder facilities must close, staff are being sacked and patients turned away.&nbsp;</p> <p>These sources of profit have not always existed. Viewing the English NHS and other European health systems as unopened oysters of profitable opportunity, corporations in the USA and Europe have worked long and lobbied hard to open public health care systems to the market.</p> <p>Ten years ago, the United States trade delegation put it like this: “the US is of the view that commercial opportunities exist along the entire spectrum of health and social care facilities, including hospitals, outpatients, clinics, nursing homes, assisted living arrangements, and services provided in the home.”</p><p>Today market predators want more than NHS funds. Claiming, as they have always done, that buying from them will save public money, corporations now want the concession to charge and sell private health care to NHS patients and introduce charges for health care and private health insurance.&nbsp;</p><p>Politicians have offered no answer to the patient protests and ‘save our hospital’ campaigns that commercialization has generated so far. Protest will escalate as the new policy hits home. So, just as Europe’s bankers have got a technocrat to destroy Greece’s public sector, including its national health service, English politicians are distancing themselves from the fall-out from NHS privatizations by vesting responsibility in a hands-off board.&nbsp;</p><p>Commercial interests and right wing ideology lie behind the Health and Social Care Bill (the <span><a class="western" href="">“secretary of state Abdication Bill”</a></span> as <span><a class="western" href="">David Owen</a></span>, a former health minister, calls it). <span>The Bill abolishes the Secretary of State’s duty to provide comprehensive health care</span> and dismantles the bodies created to deliver it. &nbsp;In their place it introduces the structures and systems of patient and service selection and patient charges. Not patient choice but choice of patient will be the order of the day.</p> <p>All of this is unpacked in a <span><a class="western" href="">series of briefings</a></span> for the Lords by health professionals.</p> <p>In a two-pronged approach, public health services are transferred from the NHS to local authorities with the functions of both so poorly defined as to bring utter confusion to patients’ and citizens’ rights. The scene is set for a re-run of the transfer in the 1990s of long-term care responsibilities to councils when funding was privatized through means testing and charges. Worse: it’s returning to pre-1948.</p> <p>Not everyone will be covered for all services in the new “NHS”. The government has gone to great lengths to ensure that the newly created commissioners of NHS services (the so-called clinical commissioning groups, CCGs) do not have responsibility for comprehensive care for all residents in <span>one geographical area</span><span>.</span></p> <p>Instead the commissioning groups will able to recruit patients from GP lists across the country. This is not patient choice. It is commissioning groups choosing patients and purchasing what the commissioning groups deem to be the appropriate NHS cover. Selection will be the name of the game.</p> <p>David Nicholson, chief executive of the NHS Commissioning Board, made this absolutely clear when he advised patients to <span><a class="western" href="">shop around across the country</a></span> for their GPs based on the range of services offered. (<span><a class="western" href="">See briefing number 4: clauses 3, 4, 6 &amp; 7</a></span>).</p><p>Clever informed middle class patients may be able to shop around for the best choice of health plans and services, just as some now do for utilities. But there is no guarantee of success, as anyone who tries to navigate electricity, gas, telecom and rail providers know. &nbsp;And try making a complaint! The information is too dense and complex, and the costs too high for the average person to understand what is on offer from complex health care packages.</p> <p>Patient choice is the great con. Patients won’t choose. They will be chosen on the basis of their risk profile. Many of the health care companies now active in the UK manage financial risk by placing time limits on care, introducing cost deductibles, copayments and restrictions on the number of GP visits, hospitals visits, operations. All are commonplace in private health insurance. They are the spectre of what is to come if the Health and Social Care Bill is passed.</p><p>The only hope is the House of Lords.&nbsp; So far peers have signalled general dissatisfaction with ill-specified transfers of fundamental ministerial powers.&nbsp; <span><a class="western" href="">Lords Owen and Hennessy tabled an amendment</a></span> that made precisely this point and although it was defeated it helped put other peers on notice that forensic examination of the Bill was needed on constitutional grounds.&nbsp;</p><p>With all party agreement on 3rd November&nbsp;the House of Lords agreed that Clause 1, which sets out the duties of the Secretary of State, would be paused and taken off the floor of the house for further deliberation until the Bill returns to the House at the Report stage. It is Clause 1 that severs the duties of the secretary of state to his people to provide and secure comprehensive care. (See our briefing <span><a class="western" href="">here</a></span>).</p> <p><span><a class="western" href="">Clauses 4, 6, 7, and 10</a></span> give extraordinary discretion to the new corporations with powers to select patients and services.</p> <p>The next few weeks are critical for the Lords.&nbsp; It is up to <a href=""><span>health professionals</span><span> and the medical colleges</span></a> to help them unpack the Bill and follow the amendments as the Lord scrutinize and debate the Bill clause-by-clause through the committee stage. Peers are taking this Bill seriously and giving it the scrutiny that the coalition’s majority prevented in the Commons. &nbsp;</p><p>The NHS will be abolished if the Bill is passed in the Spring. Were that to happen our immediate task would be to draft a short bill to restore it.</p><p><span><a class="western" href="">The briefings</a></span> show that the structures and functions crucial to protecting our comprehensive health care system are being systematically dismantled. The analysis goes&nbsp;to the heart of what is needed to restore the NHS and it goes to the heart of the government’s lack of candour about the true purpose of its reforms. 

</p><div class="field field-country"> <div class="field-label"> Country or region:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> UK </div> </div> </div> <div class="field field-topics"> <div class="field-label">Topics:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Civil society </div> <div class="field-item even"> Democracy and government </div> <div class="field-item odd"> Economics </div> <div class="field-item even"> Equality </div> </div> </div> Shinealight uk ShineALight UK Civil society Democracy and government Economics Equality Shine A Light David Price Allyson Pollock Thu, 24 Nov 2011 10:43:51 +0000 Allyson Pollock and David Price 62809 at Allyson Pollock <div class="field field-au-term"> <div class="field-label">Author:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Allyson Pollock </div> </div> </div> <p>Professor Allyson Pollock is director of the Institute of Health &amp; Society at Newcastle University. A public health physician, she is a leading authority on the <span>fundamental principles of universal health systems, marketisation and public private partnerships, and international trade law and health</span><span>. Her current research is around </span><span>access to medicines, pharmaceutical regulation, and public health; and </span><span>child and sports injury. Her book <em>NHS plc: the privatisation of our health care</em> was published by Verso, and she is currently working on a book <em>The NHS reclaimed</em>.</span></p><p>&nbsp;</p> <p>&nbsp;</p><div class="field field-au-shortbio"> <div class="field-label">One-Line Biography:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Professor Allyson Pollock is director of the Institute of Health &amp; Society at Newcastle University. A public health physician, she is a leading authority on the fundamental principles of universal health systems, marketisation and public private partnerships, and international trade law and health. Her current research is around access to medicines, pharmaceutical regulation, and public health; and child and sports injury. Her book NHS plc: the privatisation of our health care was published by Verso, and she is currently working on a book The NHS reclaimed. </div> </div> </div> Allyson Pollock Fri, 11 Mar 2011 15:57:26 +0000 Allyson Pollock 58475 at An end to Bevan’s dream of free healthcare for all Britons? <div class="field field-summary"> <div class="field-items"> <div class="field-item odd"> If the Health and Social Care Bill is passed without major amendments it will forever be known as the “abolishing the NHS” Bill. Make no mistake, the NHS will be there but in name only: health services will be run on US lines by, and largely for, shareholders and profit, while denial of care will escalate. </div> </div> </div> <p>The Government&rsquo;s Health and Social Care Bill published on 19th January is now in the Committee stage, having passed its second reading in the Commons by a majority of 86. But if the Bill is passed without&nbsp;major amendments it will forever be known as the &ldquo;abolishing the&nbsp;NHS&rdquo; Bill. If enacted, up to 100 billion pounds annually of taxpayers money is likely to be handed over to large corporations that will run&nbsp;and&nbsp;operate&nbsp;our NHS services for profit. Make no mistake, the NHS <img class="image-left" src="" alt="" width="250" />will be there but in name only: health services will be run on US lines by, and largely for, shareholders and profit, while denial of care will&nbsp;escalate.&nbsp;</p> <p>The government has sought to sweeten the pill by presenting the changes as being&nbsp;GP-led; they tell us that as Primary Care Trusts are abolished they will be replaced by GP consortiums, led and operated by&nbsp;GPs. This is of course a horrible and grotesque fiction. The outspoken chair of the Royal College of General Practitioners Clare Gerada is furiously opposing the changes, along with the BMA, RCN, NHS Confederation, and numerous other royal colleges and think tanks, medical students, nurses and doctors. The reality is that GPs are neither trained nor skilled in planning and providing health services for&nbsp;the&nbsp;whole population; their duty is to care for the patient. They know this, but have no choice now but to allow their practices to join consortium or find themselves taken over by the private sector. But they<img class="image-right" src="" alt="" width="270" />&nbsp;also know the new consortium will over time be run by shareholders for profit and in time so will all the services.</p><p>GP practices already have to compete for commercial contracts; soon these contracts will specify what services they can and can&rsquo;t provide and determine which patients they can accept. The conflict between shareholders&rsquo; demands and patients&rsquo; needs will be ever evident to patients and public in day to day practice and services provided.</p><p></p><p>The government is determined to open up the NHS to the market place and very soon the 100 billion pounds of taxpayers&rsquo; funds will be lining the pockets of new equity investors and the shareholder returns of American and British health care corporations, just as they do with PFI, pensions etc. These reforms are driven by pure market ideology, without a shred of evidence that they will benefit the British population as a whole. On the contrary, all the evidence shows that if you create a US healthcare system the result will be denial of care and exorbitant costs for the taxpayer and the patient as private sector providers hold the government to ransom.</p> <p>Under the proposals laid out in the Health and Social Care Bill, the secretary of state is in effect abolishing his duty to provide and secure comprehensive services for the whole population, while the mechanisms which enabled that to happen would also be repealed. The new consortium would have no duty to provide and secure comprehensive care as they would no longer have responsibility to all patients and residents in a defined area. Instead, local authorities may end up becoming&nbsp; providers of last resort when patients are denied or cannot get care. And as for the new consortiums, they are to be granted extraordinary new powers: the power to deny care, to close and erase NHS services and to introduce charges, top up fees and sell private health insurance. The private sector providers too will have extraordinary new rights. The right to fair and equal treatment will no longer be for patients but for the benefit of investors, who will use competition policy and trade law to demand a right of entry and a right to ensure that their services can continue to operate profitably.&nbsp;</p> <p>If the government can retreat on the privatisation of England&rsquo;s forests, it can still do the right thing by the National Health Service. On the other hand, if the Health and Social Care Bill goes unamended, it will spell the end of Bevan&rsquo;s dream and a return to fear.</p><p><em>To learn more about the campaign against the Coalition's healthcare reforms, visit </em><a href=""><em>Keep Our NHS Public</em></a><em>. <br /></em></p><div class="field field-country"> <div class="field-label"> Country or region:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> UK </div> </div> </div> <div class="field field-topics"> <div class="field-label">Topics:&nbsp;</div> <div class="field-items"> <div class="field-item odd"> Democracy and government </div> <div class="field-item even"> Economics </div> <div class="field-item odd"> Ideas </div> </div> </div> uk uk UK Democracy and government Economics Ideas OurKingdom debates the NHS Allyson Pollock Sun, 20 Feb 2011 13:08:16 +0000 Allyson Pollock 58164 at