Bevan betrayed: the demise of the NHS

Bevan betrayed: the demise of the NHS

Robert Lane

president, Association of Surgeons of Great Britain and Ireland rhslane{at}aol.com

Alex Paton

retired consultant physician, Oxfordshire PatonAlex{at}aol.com

When Labour came to power in 1997 it denounced the private finance initiative (PFI) introduced by the Tories as "creeping privatisation" and the internal market as a cancer eating away at the NHS. By 2004 the private sector had metastasised to virtually every organ of the health service.

In 1999 Richard Smith, then editor of the BMJ, wrote an editorial entitled "Perfidious financial idiocy: a ‘free lunch’ that could destroy the NHS" (BMJ 1999;319:2-3) to accompany a series of critical articles on PFI by Allyson Pollock and her team. In 2004 Richard Smith left the BMJ to become chief executive of UnitedHealth Europe, a new European arm of an American healthcare company. Simon Stevens, Tony Blair’s senior health adviser, was appointed president of the company. Former health secretary Alan Milburn invited UnitedHealth Europe to test a scheme for elderly care.

We have suggested elsewhere that the NHS is being dismantled and taken over largely by the Americans (The Health Summary (THS) 2004;21(11):6-8, The Health Summary 2005;22(2):5, and the Guardian 21 April 2005). But US health guru Barbara Starfield recently pointed out that health care in America is worse than that in the United Kingdom, and that it "remains much like it was a century ago" (BMJ 2005;330:727-9). Yet such is our love affair with privatisation that those who dare to criticise are lectured by Smith and his kind on the usual crimes of fear of change and holding up progress (BMJ 2005;330:530-3).

We are not against privatisation: all health services like ours provide for limited private health care. What we are trying to do is highlight the financial gain for those companies involved in the latest and "most radical" reorganisation of the NHS (said to be the 19th), and to draw attention to premature, ill-thought-out schemes that threaten to destroy what is on the whole a valuable institution.

To many people it is clear that the NHS is being taken over by big business and private healthcare teams, so that money that could go towards clinical care is diverted to corporations and their shareholders. As Allyson Pollock has pointed out in her book NHS plc (review BMJ 2004;329;1349), huge amounts are paid to large private firms for advice about PFI and independent sector treatment centres (ISTCs). Profits made by consortia involved in PFI are swollen by the scandalous practice of refinancing buildings, while cash-strapped hospitals must pay the mortgage for 30 years. Writing in the Guardian newspaper on 27 June this year, consultant radiologist Jacky Davis said that ISTCs, run mostly by foreign firms, were paid on average 40% more than equivalent facilities in NHS hospitals.

But problems go deeper than money. Clinicians these days are expected to provide evidence to support the actions they take; no such inhibitions apply to ideas generated by favourite government advisers and applied without consultation or listening to other views. The result is a stream of untried schemes, based on ideology rather than evidence, that often have unforeseen consequences on different parts of the NHS.

For example, Kaiser Permanente (KP), a successful American healthcare plan, has been accepted by the government as the future model for the NHS, even though the BMJ received some 70 responses on its website criticising the paper that supported KP (BMJ 2002;324:135-41); subsequent research has highlighted the flawed thinking (British Journalof General Practice 2004;54:415-21). UnitedHealth Europe was given £4m of our money to pilot Evercare, designed to look after the elderly in their own homes and reduce admissions to hospital by 50%, according to figures from America, as reported by John Carvel of the Guardian on 4 February 2005. Before these figures were known, all primary care trusts (PCTs) were instructed to prepare plans for similar schemes by 2008. Two subsequent reports by the King’s Fund conclude that evidence of effectiveness is "weak," and the percentage of admissions saved appears to be in single figures, according to the same Guardian story. At the same time, former health secretary John Reid announced with massive publicity that 3000 senior nurses were to be appointed as community matrons to look after elderly people; given the dire state of nursing numbers, no one knows where they are to come from.

Expensive ISTCs—originally said to be a temporary expedient to bring down waiting lists, but now, we hear, to be extended indefinitely and to cover more specialties—are distorting hospital practice. "Cherry picking" of easier cases leaves NHS surgeons to deal with higher risk patients that are costly and liable to increased morbidity and mortality; hospitals could face apparently poorer performance, failure to achieve targets, and financial disaster. Possibly even more serious for the future is that 20% of training opportunities for young surgeons are being lost (according to a report in the Guardian on 21 April), at a time when exposure is already restricted by the European Directive on Working Hours.

The new contract for general practice provides for a "minimum basic package," after which many traditionally provided services can be outsourced to private companies. Where, then, is the doctor-patient relationship? PCTs control 80% of the NHS budget and will strongly influence hospital practice; autonomous foundation hospitals will still need to make a profit through maximum use of beds. Competition through conflict—the sinister word "contestability"—and payment by results are the current mantra, but markets have never yet delivered universal and equitable health care.