The NHS is heading down a hole—should we stop digging?
BMJ 2012; 344 doi: https://doi.org/10.1136/bmj.e805 (Published 01 February 2012) Cite this as: BMJ 2012;344:e805
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In an earlier response to this article, Dr Mathews was absolutely right to highlight the importance of health care rationing to this debate.
I would disagree that the reforms are primarily about rationing however.
Initially, it was claimed we needed reform to reverse the UK’s flagging health outcomes. Enthusiasm for this argument has waned as government claims of poor patient satisfaction, cancer outcomes, and heart disease, have each been shown to be spectacularly false.[1,2,3]
Increasingly, cost-efficiency has been cited as a key objective but this has been contradicted by government action. For example, one of their first initiatives was to create a £50m fund for cancer drugs deemed not cost-effective by NICE, despite the fact this system produces amongst the best, most equitable and most cost-effective outcomes for cancer of all OECD countries.[2] And just recently we learned three tiers of management are to be replaced with five [4] – hardly a stride towards cutting bureaucracy costs.
Rather than being about rationing, these reforms are about blindly pursuing neoliberal, free-market policies. They are an expensive, unnecessary distraction from the essential task of rationing health care in the face of increasingly limited resources. Although markets may occasionally improve quality and micro-efficiency, they cannot be relied upon for the strategic planning needed to ration care equitably and efficiently.
Attention should be directed towards addressing health service inefficiencies imbedded in customs, rules, professional values and institutional structures.[5] For example, some of the greatest improvements under Labour came from centrally determined waiting-time targets [6], the NSF for heart disease [7], and the NHS Cancer Plan.[2] Such reforms avoid the administrative costs associated with shoehorning health services into a market model – costs which have risen from 6% to over 14% of the NHS budget since market experiments began in 1990.[8,9]
This week Mr Lansley argued his reforms did not amount to privatisation of the NHS.[10] It is important to be clear however that it is not just the privatisation, but the extensive marketisation mandated by his reforms, that threatens to destroy the NHS as we know it.
1.Appleby J & Robertson R. A healthy improvement? Satisfaction with the NHS under Labour. In: Park A, Phillips M, Clery E, Curtice J, eds. British Social Attitudes Survey 2010-2011: Exploring Labour’s legacy—the 27th report. Sage, 2010.
2.Pritchard C & Hickish T. Comparing cancer mort and GDP health expenditure in England and Wales with other major developed countries from 1979-2006. British Journal of Cancer. 2011;105;1788-94.
3.Appleby J. Does poor health justify NHS reform? BMJ. 2011;342;310-11.
4.URL: http://www.guardian.co.uk/politics/wintour-and-watt/2012/jan/27/andrewla... [Accessed 7th Feb 2012]
5.Light D. Effectiveness and efficiency under competition: the Cochrane test. BMJ. 1991:303;1253-4.
6.Brereton L & Vasoodaven V (2010). The Impact of the NHS Market: An Overview of the Literature. CIVITAS, London.
7.Smolina K, Wright F, Rayner M & Goldacre M. Determinants of the decline in mortality from acute MI in England between 2002 and 2010: linked national database study. BMJ. 2012:344;d8059.
8.Pollock A. NHS PLC: The privatisation of our health care. Verso: London. 2004.
9.URL: http://www.guardian.co.uk/society/2010/mar/30/nhs-management-costs-spending [Accessed 7th Feb 2012]
10.Lansley A. Why legislation is necessary for my health reforms. BMJ. 2012. 344;e789.
Competing interests: No competing interests
In neither Fiona Godlee's editorial nor in any of the 8 articles in the same BMJ relating to Andrew Lansley's Health and Social Bill (including his own) can I find the words "ration" or "rationing". Seventeen years ago, the BMJ's sub-editors supplied the title, "I can no longer ration" to a Personal View of mine. It is easy to understand that a polititian might wish to avoid describing a proposed change in the NHS as a means of rationing (for a start everyone in these hard times would know what was meant) but the modern BMJ has nothing to lose by using, and encouraging its contributors to use, this "R" word, where appropriate - as I think it is here.
It seems to me that the Bill is not a rabbit hole. The Bill is a pill whose active ingredient is rationing. Choice, competition, local decision making and privatisation are constituents of a sugarcoating to make the pill more palatable to some. The "reforms" are the expensive packaging de rigueur for selling these days.
All health services workers will do the best they can for patients under whatever arrangements come to pass in the NHS, but surely it is time for both politicians and professionals (especially pathfinder CCGs, if they are indeed destined to be the main rationers) to be forthright and open with the public about the rationing to come. What will be rationed to fund what? That is the question.
Mathews DD. Personal view: I can no longer ration. BMJ 1995, 311,66
Competing interests: No competing interests
I'm a public health doctor and am increasingly worried by the fragmentation and additional layers of bureaucracy that the Bill will introduce.
At the moment, for better or worse, the responsibility for the health of every individual lies with the Chief Executive and Board of each Primary Care Trust. Whether it's a problem with your GP, local hospital or public health, it is the PCT's responsibility to sort it out.
Under the new system, if you have a problem with your local hospital, you will need to take it up with the Clinical Commissioning Group which commissions their services. If it's a problem with your GP, you will need to take it up with the National Commissioning Board who will be responsible for commissioning GPs. If it is a public health issue, you will need to take it up with the local authority.
The Health and Wellbeing Boards who are supposed to hold this all together in the new system have no real power as they do not hold the commissioning budgets and in any case will not have the degree of operational oversight needed to ensure a safe system
Competing interests: I work as a public health doctor in the NHS
Re: The NHS is heading down a hole—should we stop digging?
In this article the Editor asks ‘should we stop digging?’ and stop any further destruction of the NHS. In a speech in 1948 to the BMA in an attempt to enthuse its members to support the creation of the NHS he said, “What we are doing is being watched by the whole world...... This is the biggest single experiment in social service that the world has ever undertaken”. It is the destruction of the foundations of the NHS to rebuild it on capitalist foundations of market forces and profit motives that will make the architects of the NHS turn in their graves.
The editor also states “In the absence of united opposition the bill will pass”: a clear warning and a call for action: tangible opposition.
Although we could prevent further digging, we cannot leave a gaping hole in the middle of the pavement or the middle of the road without dire consequences. Politics can be devious. Mr. Lansley seems to have dug the hole and is waiting to see how many unsuspectingly fall into it. Regrettably he has had some success. There are bound to be those within the medical profession and commercial organisations who would see the opportunity to exploit the use of market forces for personal profit. This is already happening and we should learn from experiences from the last set of reforms when some doctors warmly embraced the changes. The purchaser provider arrangements were exploited and outreach clinics sprang up. Closing down of some hospitals were not recommended, just based on strategic planning or financial considerations but also on the basis of self preservation of the survivors.
It is my opinion that one of the reasons that the government is forging ahead with its reforms, as was the reason for presenting NHS reforms as a white paper last time, is how attractive the market forces ideology, the purchaser provider theology and the facade of money follows the patient was attractive to some. This time round, there is a greater role for the private sector aimed at eventually succeeding with privatisation. The GPs are being enticed and lured with power and the opportunity to dictate the future of the NHS.
The greatly increased cost of the delivery of health care provision through commercial organisations has not been appreciated by the public. The claims of saving billions through stream lining and elimination of bureaucracy will be wiped out by the payments made to the private providers. Is there some means of arriving at an estimate of the cost to the NHS? It was too late when the damage inflicted by the PFI was publicised.
While there would be great unanimity in the country for the preservation of the NHS, there is less thought given to the means of making the opposition as effective as possible. The call for the withdrawal of the bill demanded by the politicians and the professionals and the trade unions has come too late. Many changes have already been introduced and put in place some under the guise of pilot schemes. The most vociferous opposition has been from those working in the NHS or organisations to which these members belong such as: the BMA, Royal Colleges and trade unions of NHS staff. Their protests are of great importance coming from those who are involved in patient care and hence who are acutely aware of the damages that will result from the NHS reform bill.
Important as this group is the weakness lies in that they could be seen to be motivated by self preservation. It is however extremely encouraging to note that a strong and powerful voice from the non NHS professionals is providing the much needed additional support. Contributions of Professor Chris Nedwick and Professor Martin McKee and many others are most welcome. This together with the editors of the BMJ and the Health Service journals voicing their opposition strongly would go a long way to convince the public that the opposition to the reforms by the medical professionals is driven by altruistic motives to preserve the NHS for the benefit of the people.
The basis of the opposition is also widening. I wish to support the legal reasoning provided by Professor Nedwick. In claiming that the introduction of this bill is to legislate to improve continuously the quality of care, the Secretary of state displays ignorance that the 1999 Health Act imposes duty of quality by the Secretary of State and those to whom he delegates power. Clinical governance already recognised in the 1999 Health Act incorporates the requirement for ‘continuously improving the environment in which clinical excellence will flourish’. This is another reason for redundancy of this bill in addition to the powerful arguments laid down by others.
Is there a case to follow the route of judicial review? Could there be a formal challenge to this bill? Could the Secretary of State be charged for failing the requirement of clinical governance? The legal aspects should be explored and exploited. Should there be a legal consortium to express views on this?
Finally as to making the protest most effective it is worth reminding ourselves how the poll tax was beaten. I do not believe that the dangers to the NHS has fully entered the consciousness of the people. Recognition of the consequences of poll tax determined the strength of the protest. This needs to be achieved as a matter of urgency. It was the massive protest by the people instilling the fear of losing votes that brought the government to its knees over poll tax. However strongly the medical profession and the NHS employee’s organisations might voice their protests they will not have the effect of the uprising of the people as at the time of the poll tax. The public must be made aware that the changes to the NHS will be far more damaging and longer lasting.
I know that appealing to the people to demonstrate and openly express their views conjures up images of riots and public disturbances. It is not violence that will intimidate the government. It is numbers. The politicians are not even afraid of losing their popularity, but fear of losing their seat and some their livelihood will bring about the jitters. The type of protests that have been made so far might have forced a few amendments. The NHS is not going to be saved by these amendments. The demand to withdraw the bill should be in a language that the politicians will understand with effects that can be felt. The language is the language that has achieved success in the past. We cannot wait any longer. Could the march begin?
Competing interests: Relevant interest: Preservation of the NHS