The implications of the Government’s NHS changes, and what Labour should do about them: Guest Post by Dr Nick Palmer
Matt has challenged Anna Soubry and me to comment on the Government’s NHS policy. You won’t be surprised to learn that I’m not a fan of them. But I’d like to take the opportunity to say what I think Labour should do differently if we’re elected next time round. Miss Soubry failed to come to defend the Government’s policy at the recent meeting on NHS issues in Beeston, but if she’d like to debate it here or anywhere else I’d be very glad to have a constructive discussion.
Let’s get the obvious partisan point out of the way. David Cameron promised no top-down reform of the NHS. On reaching Number 10, he and his LibDem allies introduced a reform so top-down that it was already being imposed before it got through Parliament and so huge that a senior civil servant commented that it could be seen from space. Virtually every significant medical organisation opposed the changes, and all were ignored. As an example of a broken promise it’s up there with tuition fees as a startling example, and I’ve yet to meet anyone, including senior Conservative MPs, who actually thinks it was a good idea: by the end of the process, they were just pushing it through to save face.
OK, OK, you’ve read all that before, enough already. We are where we are. What next?
There are now three main problems:
- Secondary health providers (i.e. hospitals) are being required to compete, and are encouraged to improve their funding by expanding provision to paying patients, up to 49% of capacity (typical current level is 10-15%).
- Preventative care, a key function of the old Primary Care Trusts, has been stripped out of the obligatory duties of the new Commissioning Groups. This covers things like helping people stop smoking and testing for diabetes. Would you like to see disease prevented rather than tackled after it happens? Good luck – it’s now a local authority duty, and local authority budgets are being cut to the bone. Perhaps the local authority can persuade the Commissioning Groups to do it anyway, perhaps not.
- The payments system is loaded to favour simple operations (which the private sector like to offer) at the expense of complex operations (which are usually only provided by the NHS). When the system was 90% public, this didn’t matter very much. It is now an acute problem. Expect to see more and more private providers offering to fix broken ankles and give you hearing aids, and more and more NHS providers struggling to finance the complex work.
Now if Miss Soubry responds to Beestonia, she will tell you that point 1 isn’t a problem, since the hospital is required to spend its shiny new private income on improving their service. Very true. But suppose you’re a hard-pressed hospital manager trying to meet the rising cost of complex care? You need to raise your inflow of cash from somewhere. What part of your service do you improve with income from more paying patients? Pay to expand a loss-making operating unit? Hardly. Obviously, you build a new wing entirely for paying patients. It’ll pay for itself and more, and you’ve got loads of scope to expand, all the way up to 49% of your hospital. Your bottom line will shine. What a fine manager!
But, hang on, what’s the effect of that on patients? It increases the differential waiting time. In 1997, it was commonplace to have to wait two years for a hip replacement, or two months if you were willing to pay the very same consultant to do it privately. By 2010, the average NHS wait had gone down to two months, and the private edge was reduced to having nicer carpets, posher food and prettier rooms. But now we’re starting to get insurance flyers again saying “Insure now to avoid long NHS waits.” That is going to get steadily worse until the policy changes. That is why, “We face the end of the NHS as we know it” is not a hysterical partisan claim. It’s a sober statement of fact. The end result will be a stark choice when you need care: (a) Pay or (b) Wait.
What should Labour do about it? Well, I wouldn’t scrap the Commissioning Groups. The answer to an unnecessary monster reorganisation isn’t another unnecessary monster reorganisation. I’d do five things:
- Scrap the requirement to compete (with all it implies in international competition rules), and replace it with a requirement to cooperate.
- Scrap the incentives to expand paid provision.
- Put the responsibility for preventive medicine back in the CCG’s mandate.
- Make the Secretary of State ultimately responsible for health care again.
- Pay for all operations according to cost, without a bias to cheap and easy ones.
None of this needs major new legislation, or massive new funding, or gargantuan reorganisation. It just takes the insidious incentives to private paid-for care out of the system. Oh, and make that six things:
- Don’t go back to PFI. Labour did a lot of good for the NHS, but we made mistakes too, and we should learn from mistakes. The Labour promise in 2015 should be to be better than the Tories and LibDems, and better than we were last time.
The answer to reckless privatisation is intelligent socialism – by which I mean finding ways to provide decent service to people who need it, regardless of their ability to pay. If I’m the Labour candidate next time, that’s part of what I’ll be arguing for.
Over to you, Miss Soubry. You’re a Health Minister, and appear in the press denouncing over-large croissants and the deplorable size of modern cakes. For all I know you might be right about croissants. But are you willing to debate the fundamentals of your Government’s strategy in your own constituency?