Say no to a two-tier health system / FRFI 204 Aug / Sep 2008

FRFI 204 August / September 2008

EDITORIAL
Say no to a two-tier health system

60 years ago the then Labour government set up the NHS as a universal health system free at the point of use. Now Labour is dismantling it and replacing it with a two-tier system that will provide a minimal service for the poor, and an adequate one only for those who can afford to pay extra.

Fresh from awarding United Health the management of three GP practices in April, Camden PCT is now in discussions with the likes of Virgin Healthcare to set up and run a Darzi polyclinic on the University College Hospital site. This will replace four existing GP practices.

Every PCT in the country now has to procure one new polyclinic or health centre by the end of December regardless of local needs. Private healthcare provider Assura has set out plans to build 68 polyclinics. NHS Chief Executive David Nicholson has publicly backed more private provision of primary and community healthcare services. Meanwhile Labour claims that its polyclinic proposal will not result in closure of GP surgeries has been given the lie by Haringey PCT which has published a ten-year plan where five such polyclinics would allow the closure of up to 45 practices.
Overall, spending on outsourced health services totalled £24bn last year.

However, an even bigger threat to the principles underpinning the NHS is the government’s review of co-payments. Under the current rules, which have existed since the foundation of the NHS, a patient may not ‘top up’ NHS care with privately-purchased drugs. This has affected a number of cancer sufferers who have tried to buy non-approved drugs and as a result been denied free NHS care. The outcome of the review will undoubtedly mean that co-payments will be allowed. This will of course benefit those who can afford to pay for such drugs. The foundation for a two-tier system will be laid. It is a far cry from the NHS Plan 2000 which correctly observed that ‘user charges are unfair and inequitable in that they increase the proportion of funding from the unhealthy, old and poor compared with the healthy, young and wealthy.’

As time goes by, and as the crisis deepens, the services that the NHS will provide for free will inevitably reduce, and those that have to be paid for as extras will equally inevitably increase. Former Health Minister Charles Clarke has already said that the NHS will have to start charging patients, arguing that NHS ‘core services’ should stay free but patients should pay for extras such as alternative medicines, health checks and out-of-hours visits by GPs. In a British Medical Association (BMA) debate on the issue, one doctor said research in the USA on the effect of co-payments found it adversely affected the poor – death rates in the poorest groups increased by 10% when they had to pay. This did not stop the BMA from approving the review.

NHS constitution
As part of the July NHS Next Stage Review, High quality for all: a plan for the next ten years, the government published a draft of an NHS constitution. The document sets out NHS principles together with the rights and responsibilities of staff and patients. It includes an explicit responsibility for patients to make a ‘significant contribution’ to their good health, and to ‘take some responsibility for this’. Whilst this may sound harmless, in reality it begs a whole lot of questions. How do the poor and the working class take care of their health when sports centres and facilities close down, and those that remain charge for use? How do they eat healthily as food prices rise? How do they maintain their mental health in conditions where there is no hope and no future? Ill health, physical and mental, is class influenced. The responsibility is fine for those who can afford to exercise it. Those who cannot, face a double-whammy: not only does their health suffer because they are poor, but in the future poor health may become grounds for denying free NHS care.

The draft constitution sets out ‘the commitment to a service that is for everyone, paid for out of taxes, based on clinical need rather than an individual’s ability to pay, and without discrimination of any kind’ but does not define the scope of service to be provided free. The meaninglessness of the commitment becomes evident when we look at the state of maternity services. In July the Healthcare Commission revealed that there are serious problems in maternity care, which include significant shortages of midwives and obstetric specialist doctors. The Royal College of Midwives said that the NHS is not on track to recruit the promised extra 4,000 midwives needed by 2012. Maternal deaths have increased from 10 per 100,000 births in 1987, to 13 in 2002 and almost 14 in 2007. The number of women dying in pregnancy or soon after delivery has risen by almost 40% in 20 years. At the current rate, NHS spending on maternity will fall to its lowest for ten years by 2011. Top-up services to provide additional care will of course be available...to those who can afford them.

Aneurin Bevan, architect of the NHS, once said ‘There are potent reasons why it would be unwise as well as mean to withhold the free [NHS] service from the visitor to Britain. How do we distinguish a visitor from anybody else? Are British citizens to carry means of identification everywhere to prove that they are not visitors? For if the sheep are to be separated from the goats, both must be classified.’ Now hospital trusts have Overseas Visitors Teams with the power to refuse free treatment to the ‘ineligible’. Thus the Homerton Hospital in East London, a foundation trust, has produced a document on the right to free NHS treatment, excluding information on the position of migrants, refugees or asylum seekers. Nurses, doctors and receptionists are now supposed to review patients’ eligibility for free treatment, including children, asking them questions, and then reporting any concerns to the Overseas Visitors Team who will be free to harass patients who cannot pay.

Exclusion is the watchword for Labour’s new health service: exclusion of those most in need, exclusion of those who cannot afford to pay, exclusion of foreigners. We must fight this inhuman attack on the working class.

NHS: No to two-tier health service

In 1948 the National Health Service brought to an end a system where those who could pay necessarily got better treatment. Except in so far as prescription charges applied, care was to be provided on the basis of clinical need, not the ability to pay. However, Health Secretary Alan Johnson, anticipating the results of an independent review scheduled for October, has indicated that it is very likely that the rules about top-up will be overturned and the ban on people topping up their care by paying privately for medicine while being treated on the NHS will be lifted. Yet another step is being taken towards turning the NHS into a two-tier system.

The National Institute for Clinical Excellence (NICE) was set up to stop the postcode lottery by ensuring that all drugs approved by NICE have to be funded by every Primary Care Trust (PCT) in England and Wales with a similar set up in Scotland. Until then, PCTs were under no obligation to agree the prescription of new drugs, particularly new and expensive ones required for cancer treatment. Hence the postcode lottery: whether or not a patient could get such drugs depended on where he or she lived and whether the PCT was prepared to approve.

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Health matters: Inequality in the NHS / FRFI 206 Dec 2008 / Jan 2009

FRFI 206 December 2008 / January 2009

Primary care
• In 1971, Dr Tudor Hart wrote in The Lancet that ‘…the availability of good medical care tends to vary inversely with the need of the population served’. This still applies: for instance, there are still twice as many primary care professionals per head of population in Cambridgeshire as there are in Manchester. Residents of Cambridgeshire will on average live six years longer. The Office for National Statistics released life expectancy figures recently showing that a child born in the South East and South West of England in 2005 had a life expectancy of 78.9 years for males and 82.9 years for females. This compares with Scotland, where it is the shortest, 74.8 years for males and 79.7 years for females.

• In Camden, north London, a battle has been won to defend GP services. Camden Primary Care Trust (PCT) recently announced that it is no longer planning to establish a polyclinic at University College London Hospital  (UCLH). It has backed down from its intention to move local GPs and/or new GP services to this polyclinic with a further threat of private tender to run it. This is a valuable lesson in the importance of local campaigning, as doctors, nurses and local people have kept up the pressure against the privatisation of primary health care services in the borough since the PCT’s first announcement. Campaigners opposed privatisation, demanding that money spent on the UCLH polyclinic should be spent on existing GP services in the borough and that consultation with local people about any further changes should be transparent from the start.

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Attacking the NHS

nhs for sale 

There is no reason why a wealthy nation such as Britain cannot afford a good system of healthcare, with services freely available to young and old alike. But in six months’ time the NHS will face a funding crisis of unprecedented proportions, one which will intensify in the following year.

This is the inevitable consequence of the Tory spending plans which Labour will support if it wins the election. The facts are clear: spending on the NHS has risen on average 3.5% each year in real terms over the last 17 years. Because NHS inflation is higher than the general rate, savage cuts in services and rationing are still required.

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