November 2012
Controversy and misunderstandings continue over the true implications of the Health and Social Care Act 2012. This article aims to counter some of the most common attacks on the Act. I have chosen to respond in detail to the arguments presented at http://t.co/7E9wJ57W against the Government’s NHS reforms. Suggy @TheSuggmeister challenged me to respond, without spin, to this specific article on Twitter on 6th November 2012. The entire article excluding the pictures is reproduced below in black. My responses are in red.
My political work on the NHS is carried out on a voluntary, unpaid basis and the opinions expressed are entirely my own and not sponsored in any way. However, for the sake of transparency, I disclose that I am an active Member of the Conservative Party.
Readers are welcome to address comments to me on Twitter at @barbararesearch or to post longer comments in my guestbook at http://www.researchideas.co.uk/40425379 .
The NHS is the largest healthcare supplier, biggest employer and one of the largest property owners in Europe. In any organisation as big as the NHS there will be the good, the bad and the ugly. There is no excuse for substandard service but we must not think that individual failings mean that the whole NHS is bad. It is one of the best healthcare systems in the world but we owe it to patients to try to make it even better and to the taxpayer to make it more efficient.
One reason why the Health and Social Care Act is so widely misrepresented is that it is too long and complex for most people, including medical professionals, to understand without making a huge commitment of time. Most journalists who have written about the Act have not even read it from cover to cover. Many misconceptions are repeated and become widely accepted when in fact the Act says something quite different. My thoughts on many of the issues can be accessed via my website at www.researchideas.co.uk . A readable summary of much of the Government’s present thinking on the NHS is provided by the current draft of the NHS Constitution.
THE HEALTH AND SOCIAL CARE ACT
The HSC Act was passed 27 March 2012
Crucially and most seriously, it removes the UK government’s obligation to provide universal healthcare in England, something so fundamental it amounts to the abolition
of the NHS http://tinyurl.com/4xdnobo. As Dr Jacky Davis, co-chair of the NHS Consultants Association says: "After the passage of the unwanted, unneeded and deeply undemocratic
NHS bill, we no longer have a national health service."
The first clause in the Act reads:
“1. Secretary of State’s duty to promote comprehensive health service
(1) The Secretary of State must continue the promotion in England of a comprehensive health service designed to secure improvement—
(a) in the physical and mental health of the people of England, and
(b) in the prevention, diagnosis and treatment of physical and mental illness.
(2) For that purpose, the Secretary of State must exercise the functions conferred by this Act so as to secure that services are provided in accordance with this Act.
(3) The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England.
(4) The services provided as part of the health service in England must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.”
The legal advice mentioned at http://tinyurl.com/4xdnobo was taken in July 2011, after which many amendments were made before the Bill became law in March 2012. Most of the criticisms highlighted in the link reflected drafting concerns which were addressed in subsequent amendments.
1) THE FORCING THROUGH OF THE HSC BILL
There was overwhelming opposition from the medical profession (e.g.: from the British Medical Association and all but one of the 26 royal medical colleges), though this impression
was not communicated by the mainstream media, particularly the BBC. Although the NHS affects every man, woman and child in England, most remain in the dark about what has happened. The government has played a big role in this.
There was heavy opposition from the medical profession. This point was reported forcefully in the media. In my opinion medical professionals were misled by inaccurate reporting in the media, including the BBC, and by false claims by political opponents.
It repeatedly concealed the purpose of the bill - to make possible the gradual dismantling of the NHS and its replacement in the medium-term (few years) by a market system, based on ability to pay rather than need. According to Michael Portillo: "They [the Tories] did not believe they could win an election if they told you what they were going to do [to the NHS]" http://tinyurl.com/d64qov6
There have never been any plans for the NHS to give preferential treatment to people with the ability to pay.
PART 1 CLAUSE 4 - “Duty as to reducing inequalities - In exercising functions in relation to the health service, the Secretary of State must have regard to the need to reduce inequalities between the people of England with respect to the benefits that they can obtain from the health service.”
The government also used mis-information to justify its reforms. According to Portillo, the Tories had to do something about the "incredible inefficiency" of the NHS http://tinyurl.com/d64qov6. The truth is the NHS is one of the fairest, most efficient and cost-effective healthcare systems in the world http://tinyurl.com/3qf92zc. It has half the per capita costs of the US health system - which is not universal - and has a higher life expectancy and lower infant mortality (OECD figures).
The NHS is very efficient relative to the systems in some other countries. However, all healthcare systems are inefficient because of the fundamental point that the payer (usually a government or insurance company), the chooser of the service (typically a doctor or manager) and the recipient (patient) are normally different. Soaring healthcare costs are one of the most serious problems faced by all governments and all political parties. Reducing inefficiencies is largely about aligning the interests of all the people concerned. The NHS is one of the most efficient healthcare systems in the world but it still has major inefficiencies.
The government defied a legal ruling (Freedom of Information act) to make public the risk assessment of the bill, despite the commissioner's verdict of "exceptional public interest".
It was not a legal ruling that could be enforced in the courts. It was the independent view of an appointed expert but the Government did not have to act on it. The ruling was only made because of the “exceptional public interest” and therefore indirectly accepted that circumstances exist where risk assessments should not be made public. Since the document has not been released and therefore I do not know what it says, I cannot give an opinion on whether the Commissioner or Government is right. However, the risk assessment is only one view.
There was a massive conflict of interest, with 1/4 of the MPs and Lords who voted for the Bill having financial stakes in private health companies that stood to benefit by from the bill's passage http://tinyurl.com/7gcsaqf. “Care UK”, a private health company donated significant money to the office of health secretary Andrew Lansley.
I really do not believe that many MPs were affected by commercial interests. In many cases the conflict was minimal (e.g. shareholdings in pharmaceutical companies). The Act was passed by a decisive majority of 88 in the final Commons vote, much too big a margin to be explained by the business interests of MPs.
2) SPECIFICS OF THE HSC ACT
In addition to removing the universal right to healthcare, which has existed since 1948, the Act also opens the door for charges
(without limit) for NHS services. It permits private providers to take over any NHS services. And it allows up to 49% of the business of NHS hospitals to be private. Quite apart from the fact that the intention is almost certainly to eventually increase
this percentage to 100% - ie: create a US-style insurance-based system - this will create a health system with two queues: one for the poor and one for the rich http://tinyurl.com/c7jbd2p
The Act has not removed the right to comprehensive healthcare, free unless Parliament expressly decides otherwise (e.g. prescription charges for most people in work). Private providers can only take over NHS services when patients can be shown to benefit. The suggestions about the 49% cap mentioned above are completely unfounded and arise because the media reported the issue wrongly. See the following links: http://bit.ly/zqV5fN and http://www.researchideas.co.uk/40425392 . There have always been two queues, one for NHS patients and one for private patients. However, private patients do not cause NHS queues to get longer.
In a cash-strapped system, a rich person with a minor ailment will be treated over a poor person with a more serious ailment. "Care will never again be according to need but ability to pay," says Dr Clare Gerada, Chair of the Royal College of GPs.
I do not see how the ability to pay can have an effect within the NHS when neither the rich person nor the poor person is in fact paying.
The Faculty of Public Health's risk assessment warns of 1) Loss of a comprehensive Health service, 2) Increased costs, 3) Reduced quality of care, 4) Widening health inequalities http://tinyurl.com/7z2nf2f In a nutshell: "NHS: integrated, comprehensive, cost-effective, accountable. Mix providers: fragmented, unaccountable, expensive, only profitable services." (‘integrated’ means that data is shared – something which was not the case with the private companies involved with the recent breast implant scare – and that patients receive care from a multi-disciplinary team of doctors, nurses, physios, district nurses, and so on. ‘Comprehensive’ means that all people and all ailments are treated. ‘Accountable’ means that problems are made public and not concealed by commercial contracts)
The Act requires the NHS to be comprehensive and reduce inequalities. There are safeguards in the Act to ensure that the decisions are taken on the basis of what is believed to be in the best interests of patients. Record keeping, information sharing and IT is an area where the NHS could have done much better and has wasted a lot of money. Organisations do not have to be state-controlled in order to communicate effectively. Stock exchanges, for example, are very efficient at providing and storing information. Examples of poor communication can be found both in the NHS and in private companies.
But the risks highlighted by the Faculty of Public Health are all short term. The NHS is being removed gradually (No government would dare remove it in one go. At the time of the last election, it had the highest-ever public approval rating). However, the end-game is an insurance-based system like the US where, without health insurance, you will not be able to get treatment for you and your family. The term NHS will be meaningless. "The NHS will be reduced to a logo, a budget and a few qangos," says public health physician, Dr Alex Scott-Samuel.
The NHS is not being gradually removed. It is growing as a proportion of the economy and expenditure on it is growing in real terms. Advanced countries that rely very heavily on medical insurance typically make it compulsory or very strongly encouraged. It is effectively just another form of tax. There are no plans to follow this model in the UK.
3) WHAT HAS HAPPENED SO FAR
Most people remain in the dark about what the HSC Act does because of failure of the mainstream media. As has often been said on Twitter, if the BBC covered economics
like it has health, nobody would know there had been a global financial crisis. On the day the Act was passed the strap-line across the bottom of BBC News broadcasts said "Bill which gives power to GPs is passed". It would be difficult to find a GP who agreed
with that.
The Act does in fact give a lot of power to GPs, although I accept that the Act is not popular with GPs. It is worth remembering that GPs originally opposed the creation of the NHS.
At a time of severe financial pressure, huge sums of money – estimated at more than £3 billion - are being diverted from patient care to fund the reorganisation necessary to implement the HSC Act.
Total NHS expenditure in the UK is around £125 billion per annum. In this context £3 billion is under 2½% of NHS spending. The purpose of the reorganisation is to make the NHS more efficient over the long term.
The implementation of the HSC Act is creating huge amounts of duplicated bureaucracy – the principle cause of the high cost of the US healthcare system. Just some of it is spelled out here by the editor of Nursing Standard http://tinyurl.com/cu8lkjg
Most reorganisation increases costs in the short term because the new arrangements often need to be put in place before the old ones are dismantled. This process is investment for the future.
The principal cause of the high cost of the US healthcare system is the high income of doctors, nurses and other medical professionals, together with an ethos of accepting expensive new technologies rapidly. Whilst the NHS has many strong points, its track record has been disappointing in areas like cancer where costly new drugs and treatments have an important role.
Gradually, the government is starving the NHS of money. This is deliberate. As hospitals run out of money - and the exorbitant repayments on PFI deals are a major factor here - they become prey to takeovers by private companies. This has already happened, with Serco taking over Newmarket Hospital.
The Government is not starving the NHS of money. It is investing. The pressure, which all countries are fighting, arises because people are living longer (leading to more NHS spending on the elderly) and scientific advances result in more sophisticated treatments that cost more. The Government is spending as much on the NHS as it can afford.
Not only does a private company cherry-pick profitable services but it gains infrastructure paid for by the taxpayer. It can also give preferential access to equipment such as kidney machines, blood and organs that were specifically donated by the public to the NHS for use by everyone.
The Act is extremely long. It spent a year in Parliament, faced over 1,000 amendments and has undergone more scrutiny than any other piece of legislation in living memory. There are enormous safeguards. I do, however, share some anger about the fate of donations, including ones that I have made personally.
NHS services must be put out to tender. The core business of the transnational corporations that are bidding is winning government contracts, as they have the experience, deep pockets and legal expertise to do so. Small enterprises and local GPs cannot compete with them in tendering for services as has already been seen in the Virgin takeover of community services in Surrey and children’s' services in Devon.
All relevant considerations should be taken into account by those awarding the contracts. These people are not politicians and are there to do the best for patients.
When private companies fail, such as the company with the contract for GP services in Camden, London, patients are high and dry.
The Act contains provisions to ensure that patients are not left high and dry.
The starving of the NHS of money to force the pace of its sell off to private companies has forced the imminent closure of 4 out of 9 A&E departments serving NW London.
The fundamental problem is that with ever more sophisticated medical options, only a large hospital can have all the expertise necessary to handle any emergency.
Trusts are getting together in cartels to force down nurses' pay, though nurses have experienced a pay freeze (ie: pay decrease, taking into account inflation) for several years now.
Nurses’ pay does not benefit from centralised, state control because with only one employer negotiation is harder for nurses.
Dr Peter Carter, Chair of the Royal College of Nurses is predicting the loss of 56,058 nursing jobs.
There are currently about 400,000 nurses employed by the NHS. I do not like to see anyone lose his or her job, especially nurses. My research has not covered numbers of job losses. However sad it may be, the employment of nurses is a local matter and the top priority must always be patients.
The fragmentation of the NHS is reducing data sharing, making it ever more difficult to assess how healthcare is worsening.
This issue must and will be addressed as part of the reorganisation programmes. The data to make good management decisions must be available