Does anyone understand the government’s plan for the NHS?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e399 (Published 17 January 2012) Cite this as: BMJ 2012;344:e399
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Perhaps Martin McKee should advise his students to brush up on their Alice-in-Wonderland: what it is it wouldn’t be and what it wouldn’t be, it would. The Health and Social Care bill is being implemented before it has passed into law and the Government argues that, despite the discord and turmoil it is creating, it would be chaos to turn back. At the same time, the doctors who have forged ahead with the government’s plans without any legal imperative wish that it wouldn’t be and call for the bill to be withdrawn.
Competing interests: No competing interests
The bankers SS "Greed is good" may have hit the rocks and the captain been bailed out leaving little people to suffer. Yet slow learners in government follow the same market fantasy and steer the SS “NHS” onwards, ignoring McKee's lighthouse.
To answer the questions; Point one.
Follow the money. The corporations and individuals who fund US/UK political parties want a slice of the action.(1) Neoliberal economists cannot comprehend public service and civil society and believe naked greed with free markets alone offer salvation. So markets must be created. They cannot abide billions spend on patient care without the markets getting their snouts in the trough. The faithful justify this from their supply/demand graphs. The spin offered by politicians as justification is as false as the warmongering justification of Iraqi W.M.D.
Point Two: By their fruits shall you know them. The actions speak louder than words and power is being centralised to promote markets. GP complicity is an illusion since all will be obliged to join GPCCs or be sacked. There is a sensible homeostatic rearguard action from the NHS management, using the GPCC authorisation process, to keep organisational memory, financial control and waiting time focus. Real power is moving away from GPCCs towards the Health Secretary and his sponsors.
Point three. As with solar panel tariffs where the payments were cut before the consultation ended, it is clear that parliamentary is being sidelined. Jumping the gun of passing the bill into law the secretary of state has mandated PCT/GPCCs to offer up three NHS services on the alter of free market faith (2). Disintegration of care will follow. The experience of PFI disasters (3), half-empty ISTCs (4)or exploding breast implants does not shake the faith of the zealots. So expect more centrally directed privatisation using Monitor and European competition law.
How sad that the years in opposition did not give the Lansleys a vision for the future, rather than carrying on the work of New Labour in commercialisation.(5) A truly locally based service, under clinical direction of doctors and nurses would have saved patient journeys and cut carbon as we face climate change and peak oil. This is not on offer. Instead it is full steam ahead into the rocks.
1 http://www.bmj.com/content/342/bmj.d2917 lobby watch
2 http://healthandcare.dh.gov.uk/any-qualified-provider-2/ Any willing provider
3 http://www.bmj.com/content/324/7347/1205?tab=full PFI
4 http://www.bmj.com/content/338/bmj.b1421 ISTCs
5 http://www.telegraph.co.uk/news/politics/8305506/Wife-of-Health-Secretar...
Competing interests: GP principal following NHS founding principles.
If one views the government's plan as an attempt to improve the NHS, it makes no sense at all. However, if viewed from an economic standpoint, and seen as a classic Friedman school move to create a crisis in order to facilitate the privatisation of public services, it makes complete sense. This can hardly be shocking news to anyone with even a basic understanding of economic thinking over the past 3 or 4 decades.
Competing interests: No competing interests
The UK Government’s plans for the NHS are indeed difficult to understand. What is announced, and what is written and what is discussed all seem to be quite unrelated. Those with a cynical bent might see this as Orwellian: it is difficult to articulate an opposition when the thing one is opposing cannot itself be described. So the opponents get blamed for being confused in their opposition and hopefully (for the government) argue amongst themselves.
I however take a different view. The secretary of state has a very clear view of how the NHS should work. This view was formed in opposition, just as that of the previous administration was. Indeed, the two government’s initial plans are almost identical. For PCGs, read CCGs and for “Nurses and Doctors in charge” read “Doctors in charge”. Andrew Lansley consistently promotes his vision with great clarity. (Whilst I would not have come up with such a vision, I have to concede that it has some merit).
The difficulty is that the plan has to be implemented by the Department of Health managers, who have a policy of “government-proofing” their own vision for the NHS, which certainly does not include a loss of power from the centre. The mandarins have therefore exerted their influence and written the Health Bill in such a way that it enshrines the status quo, but using a new language. The same thing happened to the previous government who became so infuriated with the inertia of Health Authorities, that they abolished them. In their cool and quiet fashion, the managers migrated into the PCTs in a process known as “Shifting the Balance of Power (SBOP)”, where they continued to do what they had always done before, and in greater numbers than ever before.
Understanding the plans as a dynamic interaction between a slightly right-wing Secretary of State and slightly left-wing Department of Health CEO is one thing, making the whole thing work is something else. I worry that those in charge are pulling in too many directions for this project to be a success.
Competing interests: I am employed by a number of NHS organisations.
Please sign the e-petition and force another debate in parliament - and encourage everyone you know who cares about the NHS to do so. It needs 100,000 signatures, approaching 35,000 so far....
http://epetitions.direct.gov.uk/petitions/22670
thank you
Competing interests: No competing interests
We read Professor McKee’s article on the digestibility of the governments Health Bill with interest (1). It compliments another article The BMJ ran on “Clinician Engagement” by Caroline White (2). Both articles show undertones of the clinician’s adversity to NHS policy making and NHS management.
If the NHS is our universe then the patient should be at the centre of it and everything we do. With this in mind we feel that medical management, “clinician engagement”, and policy making should be introduced to doctors right from the very start of medical education i.e. at medical school. This will equip students to better understand what happens right from Government policy making to Hospital Management and the implication this has ultimately to the patient.
Our concern is that this aspect of medical training is left too late; and by the time very senior doctors are working alongside management and policy makers they have already become too jaundiced about “the system”. Giving medical students the skills to understand and become involved in hospital management early on in their career is key.
Basic Medical Sciences, Physiology and Anatomy are core to medical education. However we wonder if there is much needed room for “Clinician Engagement” covering topics of Health Policy, Governance and Management. We feel that only if this practice is introduced very early in medical training; only then will future doctors have greater democracy, genuine interest and “engagement” in the future of our health service in order to better serve our patient.
References
1. Martin McKee; Who understands the Government’s plans for the NHS BMJ 2012;344;e399
2. Caroline White; Clinician “Engagement”; BMJ Careers 2012
Competing interests: No competing interests
Professor's Mckee's lack of understanding of the reasons behind the new Health Reforms is not surprising as he is not a GP and not actively involved in commissioning health care. As a GP who has been involved in commissioning for the past 8 years in a health economy that is permanently in deficit, the reason is clear. Yes it is about money and the affordability of future health care, but it is also about changing the focus of care from reactive to preventative. Until recently, heavy investment into the NHS, has just resulted in a ballooning of acute medical services. Improved health, as any public health physician should know, is all about education, housing, employment and good social care. The new health reforms are all about reversing this trend. They are about focussing on all the determinants of health, focussing on a patient's and a population's needs. They are about trying to decrease health inequalities and minimise variation in health outcomes. they are about treating people not just their illness. Basically they are about putting the 'H' back into the NHS.
Competing interests: Elected member of the Cambridge Shadow Clinical Commissioning Board
Martin McKee is not alone in his bwilderment about the government's plans. We cannot help him because he is right. I am also truly bewildered and frightened. The medical profession needs to ask questions about the role of parliament reagardng this Bill. I for one will be writing (again) to my MP
Competing interests: No competing interests
It was pleasure to read Professor Mckee's article. Perhaps with my cynicism I might be able to shed some light on the governments proposals. I do believe it comes down to money and cowardice.
We largely except that we can't pay for all that we have been, and need to look at our services and essentially decide on what should be cut. I think this is the initial drive to move Mr Lansley to formulate these plans.
But unfortunately Mr Lansley doesn't have the courage to either vocalise this or even take responsibility for the new system's failures (if) and when it happens. But here I do indeed see something a little more sinister going on. I suspect here Mr Lansley wants the responsibility for the systems failures to come back to the doctors themselves rather than himself as the Health secretary.
But Professor Mckee is right to question these changes from every stand point as if the reasons for them are as I have outlined then we really have reason to be worried for the future.
Competing interests: No competing interests
Re: Does anyone understand the government’s plan for the NHS?
Perhaps one should try to see the purpose of the Health and social Care Bill from the point of view of a member of one of the web of neoconservative “think tanks” such as “Reform”, so intimately linked with Mr Lansley1that seem to be dominating a wider political discourse.
From this perspective; the NHS, local councils, independent policing, universal education and social welfare, are components of a “socialism” that is sapping the vitality of our nation and blocking the “freedom” to “progress” of our mercantile civilization. It follows that these invidious impediments should be eliminated by whatever expedient. An occult procedural coup d’état by an alliance of un-elected and un-mandated political parties using a financial crisis as a pretext would offer the bonus of emasculating a major impediment to “Freedom”; the democratic process of parliament. In other words the bill coherent if regarded as a smoke screen for “dirty work” but is only part of a wider agenda.
After attempting to imagine this perspective, I ask myself if professor McKee shares my despair.
1 Cassidy J. Reform. BMJ 2011;342:d2917
Competing interests: Dedicated to the principles of the original NHS