What are the dangers to the NHS in the Health and Social Care bill?
I’ll start by explaining the health and social care 2011 bill which is about to have its second reading on September the 4th in the House of Commons. The government suspended the passage of the Bill in May because it had created so much controversy and convened a group of the great and the good, known as the Futures Forum, to conduct a listening exercise and respond to the Bill.
It was a political exercise and heavily stage managed with little reference to evidence; following the summer recess it is set to be rushed through parliament with government assurances that all concerns have been remedied. The main concern of this bill as set out in our BMJ paper is that the bill as amended doesn’t actually rectify our key concerns.
These are that the Ministerial duty to provide or secure provision has been repealed along with the sections which would have delegated those functions to the secretary of state for health. So in effect what will be established is an independent NHS free of direct parliamentary control. The secretary of state for health will no longer be able to delegate or instruct or issue guidance to the national commissioning board or to the new national commissioning bodies and groups which are being established. So de facto as the legal analysis commissioned by 38 degrees tells us, that’s the end of the NHS, a national health service.
Increasingly there will be enormous variation in who gets access to care, on what basis and what is paid for and what is free at the point of delivery.
The second big problem is that the requirement that primary care trusts had to serve all residents within a geographically defined area on the basis of need is also dissolved and so it’s no longer clear whether the new bodies, which are being created, will serve geographic populations. The big implications are for resource allocation and second for planning; in theory resource allocation mechanisms work on the basis of the needs of their population. New commissioning bodies and new commissioning groups if they can pick and choose patients or patients can elect to go to them from across the country it will make fairness of resource allocation virtually impossible. So that’s very significant.
A further concern is that it enables the further break up and privatisation of the NHS, so increasingly these commissioning groups will be able to contract out care to for profit and not for profit providers thus exposing the NHS to competition policy and competition law. Since competition law trumps public health, this will make it increasingly difficult to plan, to monitor and to provide on the basis of need. The new commissioning groups will find it very difficult and increasingly local commissioning groups and the bodies answering to the commissioning board will have increasing power to determine what is NHS funded care and what is non-NHS funded care and thereby introducing the spectre of top ups and user charges. Top ups are already permitted for some aspects of cancer care, the Richards report enabled that to happen unlike Scotland which went in a very different direction.
The way in which the NHS is being reconfigured is in the model of US style health maintenance organisations. What we will see is the break up of national funding stream for the NHS so it enables new sources of income to be generated by the private sector namely through user charges and sale of private health insurance. So we will be moving much more towards a mixed funding system which is the current situation in the US; whereas NHS services may not be charged for, increasingly commissioning groups will have the ability to decide what is and what isn’t NHS services in their patch and thus what services are charged for.
Is the Private Finance Initiative (PFI) contributing to the current financial crisis many hospitals in England now find themselves in?
PFI has been shown to be a factor because the PFI charge takes a bigger share of the hospital budget over time and this no doubt is creating more deficits and fuelling mergers and service closures.
Are there differences now between Tory and Labour policies towards the NHS?
The problem is that New Labour inaugurated or developed many of these policies on privatisation in its NHS Plan 2000, under Milburn so New Labour actually inaugurated the plan for privatisation and there’s no clear sign that Labour is trying to put clear water between it and the New Labour policy of 2000.
Is Scotland different from England in how the NHS is configured?
Scotland is committed to a publicly administered health service which is integrated around health boards and retains mechanisms of redistribution and direct ministerial control, how long that will last remains to be seen. Expenditure cuts for the NHS in England, will be meted out in Scotland. So Scotland will find itself in a real bind committed to maintaining a national health service but against a background of the treasury cutting the budget for both England and for Scotland and forcing and driving more privatisation and greater exposure of services to competition policy.
Finally what are the implications of the Health and Social Care bill for the NHS in Scotland?
I mean I think that’s a really important question to ask and perhaps one that’s worthy of legal and policy analysis. It’s not unlikely that there will be challenges, it may be that patients in England will come to Scotland for treatment that they can’t get in England or they may move. A second question is the extent to which competition policy, when England starts to open up its services, will rear its ugly head in Scotland. Scotland already has more PFI per head of population so expenditure pressures are problematic and it may be hoist with its own petard or rather variants of PFI.