Intended for healthcare professionals

Observations Life and Death

No power for the people

BMJ 2009; 339 doi: (Published 14 September 2009) Cite this as: BMJ 2009;339:b3735
  1. Iona Heath, general practitioner, London
  1. aque22{at}

    The public’s powerlessness to affect local policy in the NHS in England is profoundly depressing

    NHS Camden is the new name for Camden Primary Care Trust—a name that manages to be both misleading and megalomaniac. This most local outpost of the English Department of Health seems ever more intent on awarding successive contracts to private for-profit companies despite mounting opposition from residents and health professionals and in the complete absence of evidence of benefit for patients. In 2008 UnitedHealth UK was awarded the contract to run three general practices in Camden (BMJ 2008;336:412-3 doi:10.1136/bmj.39496.687245.DB), and since then every service put out to tender by NHS Camden has been awarded to a private provider. In August a new GP led health centre was offered to Care UK, even though the public consultation on NHS Camden’s primary and urgent care strategy will not be completed until October.

    This consultation is a travesty and provides a close and dispiriting encounter with the realities of accountability and transparency in today’s NHS. It begins by inviting agreement with a series of very broad local health priorities, which include reducing health inequalities and improving mental health services. It then asks: “Do you support our plan to expand primary health care in Camden through our polyclinic programme?” It offers no alternative policies and goes straight on to ask: “Which services should go into our local polyclinics?” This is not consultation, it is manipulation. A later question asks “Do you support the development of a range of services at the new GP led health centre?” but fails to mention that the services have already been tendered. There has been no attempt to survey public opinion or the views of health professionals working in Camden in a way that could be considered statistically valid or defensible. The powerlessness of ordinary people to affect local policy in the unfortunate English part of the NHS is profoundly depressing.

    The only truly democratic influence on the activities of NHS Camden is the health scrutiny committee of the local borough council. This committee discussed the draft consultation document in June and recommended a number of improvements, none of which seem to have been implemented. The committee also indicated that the tender process for the new GP led health centre should be postponed until the end of the consultation, and clearly this has also been ignored. Yet this is the limit of the powers of the health scrutiny committee—to scrutinise and to recommend: “In any case where the committee is concerned about the adequacy of consultation undertaken by the NHS body, in relation to content and time allowed, or considers that the proposals would not be in the interests of the health service in the area, it may send a written report to the secretary of state giving clear reasons for those views.” So the loop closes with the secretary of state, who is driving the policy in the first place.

    As soon as you begin to question where the real power lies, you discover what could be a quagmire of real or potential conflicting interests. In June, Mark Britnell, the NHS’s director general for commissioning and system management, who has been instrumental in opening up the NHS to for-profit companies and the driving force behind “world class commissioning,” left the NHS to join the private company KPMG. Britnell also created the “framework for securing external support for commissioners” (FESC). On its website UnitedHealth UK proudly declares that, under FESC, it is “a preferred supplier by the Department of Health to support Primary Care Trust commissioning capabilities,” while it is, at the same time, applying to provide commissioned services. Mark Hunt, the managing director of primary care services for Care UK, was previously responsible for designing policy in the strategy unit of the health department. These are just two of the ever growing number of civil servants and politicians leaving the department to take up lucrative positions with the private companies that are profiting from the policies they have helped to create.

    Only days ago a report from another FESC preferred supplier, McKinsey, was leaked to the Health Service Journal ( The report is said to have suggested that 137 000 NHS jobs should be cut to save £20bn (€23bn; $33bn) by 2014. Anyone directly involved in the care of patients is aware of waste in the service, but none would suggest that this includes the precious time that healthcare professionals have to spend with patients. Much of the waste that they would identify, however, makes up the more dubious content of NHS Camden’s strategy, including the fragmentation and duplication of services to encourage “competition” and “choice”; the loss of continuity of care, which actively undermines clinical judgement; and the contracting framework, which means that people must be prevented from attending accident and emergency departments and hospital outpatient clinics by the provision of a “GP led” health centre where people not registered with the centre can be seen without an appointment but where 90% of the contacts will be with a nurse rather than a doctor. To this list must be added the profligate use of heavy handed financial incentives across the service and, perhaps most wasteful of all, the vast but mostly unspecified amount of money spent on external advice from organisations such as McKinsey, KPMG, and UnitedHealth UK. According to the Times the bill for management consultancy advice in the public sector in 2005-6 was a staggering £3bn.

    Many ordinary people are unhappy about what is happening to the NHS, but only when the democratic deficit becomes an electoral liability will anything be done to correct it.


    Cite this as: BMJ 2009;339:b3735

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