How the secretary of state for health proposes to abolish the NHS in England
BMJ 2011; 342 doi: https://doi.org/10.1136/bmj.d1695 (Published 22 March 2011) Cite this as: BMJ 2011;342:d1695
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"Looking forward to a world where the health department does not own
hospitals" - this is the mantra chanted by the new Health Secretary Andrew
Lansley at the launching of the controversial white paper on NHS reforms
(Equity and Excellence: Liberating the NHS). The aim to "create the
largest social enterprise sector in the world" by entrusting the provision
of national healthcare services in the hands of private sector enterprises
is essentially turning the NHS into a National Health Market, with the
government diminishing its roles to that of a payer and regulator. Such
confidence in market-based reforms and solutions are ostensibly based on
political ideals and dogmas rather than any form of evidence or
experience. If any, the healthcare system in the US should have provided a
vivid indication of the appalling outcomes (high cost, poor health equity)
of a health system ridden with elements of commercialization and business
incentives in the provision of care.
Pollock and Price have given us a critical account of how damaging
the new radical reforms will be to population health should the current
version of the Health and Social Care bill is carried through. The
injection of a plethora of market-based solutions is set to revolutionize
and challenge the bedrock in which the spirit of universality the NHS is
based upon. While such changes may seemingly concern mainly the British
population, they might also impose far-reaching implications outside the
UK border. The NHS is the pioneer of universal, publicly financed health
insurance, and could probably be credited with much of the improvement in
the health of the British population since its creation. It is admired and
in varying degrees imitated worldwide, especially but not exclusively in
former British colonies. In the instance of Malaysia, for example, the NHS
is considered as a role model which appears in its current national
policies (i.e. Government Transformation Programme, 10th Malaysian Plan).
Hence, should the new reforms proved to be a public health catastrophe,
those following this lead are likely to succumb to similar failures.
Letting market forces decide through archaic rules of supply and
demand to shape the provision of healthcare services correlates with the
notion of 'patient choice'; a highly emphasized doctrine that a
'liberated' NHS will be able to provide. But when private markets dictate
healthcare access, quality, and cost, is there really a choice for
patients who are chronically ill and poor? Local authorities are set to be
providers of last resort but they mainly run nursing homes for long-term
care and lack adequate hospital facilities.
'Liberating the NHS' hence is akin to releasing a sacred public
institution that is prone to market failure into the wild jungles of
capitalism where global private investors are ready to pounce. The current
set of reforms introduced by the coalition government is essentially
turning a basic human right into a trading commodity, and patients into
customers. Reflecting the wise words of Aneurin Bevan, "A free health
service is a triumphant example of the superiority of the principles of
collective action and public initiative against the commercial principles
of profit and greed".
Competing interests: No competing interests
This article lays bare the Bill. This is a moment in the history of
the NHS that we should not ignore or just hope will go away. The BMA
chooses to "critically engage" despite the lack of evidence of any real
listening by Lansley, bar the minuscule concession on tariffs, and we are
are faced with what the authors rightly predict is the proposal to
"abolish the NHS in England".
I was at the BMA's SRM and the meeting seem to make the correct diagnosis
- that the the Bill was rotten or at least seriously flawed- but it failed
to take the necessary measures for cure. The profession along with health
unions and patient groups must fight this Bill in its totality. We
cannot, as the grass roots Liberals hope, amend a few parts and thus
temper the beast. Every Pathfinder Consortia that "makes the best" out of
the dog's dinner that Lansley's Management of Change has left, should stop
and protest rather than collude. Lansley has constructed a trap for well-
meaning GPs, with the commissioning functions (of the PCT) being
dismantled before the new arrangements are even fully fleshed out yet
alone legislated for. GPs should tell it as the authors do. We are
watching the the NHS in England and must march, lobby, maybe even take
industrial action until the Bill is withdrawn
Competing interests: No competing interests
Dear Editor,
I am grateful for the analysis of Pollock and Price, which explains
my Kafkaesque correspondence with the Department of Health (DH) since 13
December 2010. (1)
I forwarded a Low Priority Procedure (LPP) list to the DH which had
been circulating in the primary care trust (PCT) since August 2010,
setting out which services would no longer be available, asking whether it
could be right that certain treatments were excluded locally, contrary to
the pledge in the NHS constitution that "The NHS provides a comprehensive
service, available to all". (2)
I do not wish to bore the readers with the tedious exchange leading
to "However, I should assure you that there is a statutory obligation on
the NHS to provide funding for treatments and drugs recommended by the
National Institute for Health and Clinical Excellence (NICE) within three
months of the final NICE technology appraisal guidance being published."
The original LPP list has bariatric surgery and chronic fatigue
listed amongst the unavailable treatments and these have been assessed by
NICE, so the logical next question was how the DH would enforce the breach
of statutory obligation of the local PCT?
"We have replied to you on this matter previously, and in setting out
the Government's position on this issue, we have answered your questions
fully. Therefore, we will note any further correspondence from you on
this matter, but we may not reply unless the Government's position changes
or any new information becomes available."
True to form my protestations that the question has not been
addressed have gone unanswered. It seems therefore that we have already
reached the state where local health authorities can more or less randomly
decide which treatments are excluded from the 'comprehensive' package with
impunity and that this is not a future issue to worry about like Pollock
and Price indicate.
1) Pollock A and Price D. How the secretary of state for health
proposes to abolish the NHS in England. BMJ 2011; 342:d1695.
http://www.bmj.com/content/342/bmj.d1695.full
2) The NHS constitution. Department of Health. 08 March 2010.
http://www.nhs.uk/choiceintheNHS/Rightsandpledges/NHSConstitution/Docume...
-constitution-interactive-version-march-2010.pdf
Competing interests: No competing interests
As there is no overwhelming evidence in support of the proposed
changes to the NHS (1) as detailed in the governments' recent white paper,
ethically the proposed changes can only take place in the form of a trial.
I ask you to consider favourably the following study proposal which I
submit without permission on behalf of the UK government.
Title: Reorganisation of the NHS in England
Background: The National Health Service in is its 63rd year. It is
suffering the same demographic and technological challenges as all high
income countries, specifically ageing of the population and increasingly
expensive new technologies. These are major problems that we seek to
address.
We also have concerns about outcomes in the NHS when compared with
other countries. France spends more on healthcare than the UK, has fewer
deaths from heart attacks than the UK, and will shortly be overtaken by
the UK in this mortality measure. We determine from this observation that
the UK healthcare system is not delivering as much as it should and must
change, but not to be like France in funding or structure, and hopefully
not in the trend in heart attack deaths. We do not consider this to be an
ecological fallacy, and we do not consider any other differences between
the populations of France and England. (2)
Study design: Immediate full scale roll out without control or
comparison group.
What this study adds to the current evidence: We offer no global,
systematic appraisal of current evidence, and take no account of quality
of evidence. As lawmakers evidence in the legal sense is our primary
concern: oral and written statements from individuals and organisations,
and we do not distinguish this from higher quality evidence. (3) We are
confident that this study will accrue a substantial body of similar (grade
5) non-evidence with which to inform future reorganisations.
Study population: The entire population of England, of all ages, is
served by the NHS, with the exception of the most wealthy, who will be
exempt.
Interventions: 1. A market based healthcare system; open to all
willing providers. 2. GP based commissioning and the closure of primary
care trusts. 3. Transfer of public health to local authorities. 4.
Providers that cannot generate enough profit will close, whereas those
making the largest profits will succeed, irrespective of the clinical
performance. Taxpayer funding will continue, allowing successful firms to
become a conduit of money from the many to the few.
Comparison group: None
Outcomes: No a priory health outcomes are specified, although
multiple testing, case studies and post hoc analyses are planned by all
political parties for election purposes and generation of low grade
evidence.
Ethical considerations: No ethical approval has been sought. We
acknowledge the risk associated with changing the health service, and are
aware that small changes in important health outcomes can cause or prevent
thousands of deaths. (3) As we are certain that our approach is correct,
we have no stopping criteria.
Consent: Population level consent sought and an election almost won
on the basis of: "No top down reorganisation of the NHS". No consent
sought on the specific interventions.
Costing: Estimated ?1Bn to ?3Bn, with potential future savings.
Taxpayers are the sole funders.
Potential conflicts of interest: None declared although newspapers
report the secretary of state for health has received ?21,000 from the
chairman of Care UK to fund his personal office. (4)
Thank you for consideration of our proposal.
1 Pollock A and Price D BMJ 2011 342:d1695; doi:10.1136/bmj.d1695
2 Appleby J BMJ 2011; 2011; 342:d566
3 Letter from health minister Paul Burstow MP
http://www.guardian.co.uk/society/2011/feb/08/deconstruction-of-the-nhs-
bill?INTCMP=SRCH
4 http://www.telegraph.co.uk/news/newstopics/mps-expenses/6989408/Andrew-
Lansley-bankrolled-by-private-healthcare-provider.html
Competing interests: JJL is both an NHS patient and an NHS employee.
A Completion Thatcheroplasty
Our once glorious National Health System has become a sluggard and a
drunkard. The enormity of the slothfulness through the haemorrhaging of
capital funds on ridiculous enterprises that drain vigour and enthusiasm
from junior trainees and our nursing colleagues, through to the noticeable
sheer lack of pride and patronage in our National Health System, is
endemic of the warped sense of professionalism expressed by ourselves.
Through the systemic neglect from senior clinicians and senior
nurses, to leave our once glorious health system in a more noble fashion
then when they entered it, upon their departure from it, the catastrohpic
degradation in our resourcefulness to implement sound improvements is the
most significant conscious and unconscious factor in its demise.
Such a decline does not occur overnight and although the Secretary of
State for Health demonstrates some psychological malfunction by his
persistence to push through his grandstanding health care reforms, similar
to signing a DNA-CPR form for a patient rather too quickly, the legions of
doctors and nurses have still not taken to the streets but adopted their
classic approach to whisper and moan quietly in the corner.
Health care professionals are exquisitely good at this rather British
character defect. As one of my senior colleagues expressed: the golden age
of medicine in this country is over. Oh? One deduces he means the golden
age that permitted senior colleagues to neglect the cries of juniors for
improvements sooner thus resulting in the fiasco that is MMC. The
neglecting of proper structured clinically lead management structures
requiring successive secretaries of state for health to implement more
unsound structures due to our collective slothfulness to engage. Oh that
golden age?
Of course the health care reform plans from someone that should
understand our clan is a completion Thatcheroplasty. Children often forget
the inherent worth of a good thing until it is snatched from them. The
same is true for us. Sadly. Perhaps when private medicine does reign a
rampant in our society more attention shall be placed on doing things
properly thoughout the entire hierarchy that is health care as opposed to
the shoddy implementation in our current climate.
Sadly, money earned attached to your reputation is a greater
stimulator to upgrade your game plan then money detatched from your
professional persona when it comes to overall workforce planning and thus
patient care.
Time shall tell
Competing interests: No competing interests