The ConDem coalition is intent on destroying the NHS. The Health and Social Care Bill as it stands will allow private companies to decide what health services are to be provided and who will be entitled to them. It will allow these private companies to use competition laws to challenge public policies that impair their profitability and freedom to operate. These private companies will also be able to select their patients, determine staff terms and conditions, and generate and distribute surpluses to shareholders, investors and employees by underspending the patient care budget. Private interests nakedly determine public policy; profit will replace universal health care, and the working class will pay.
Allyson Pollock charted the last Labour government’s steady privatisation of the NHS in many articles and in her 2005 book NHS PLC – the privatisation of our health care. Now, together with David Price, she has dissected the Health and Social Care Bill in the British Medical Journal (BMJ 2011; 342:d1695, 22 March 2011) and exposed its utterly inhumane nature.
The first 1948 NHS Act imposed a ‘duty’ on the Secretary of State for health ‘to promote the establishment … of a comprehensive health service’. The 2011 Bill now says the Secretary of State ‘must act with a view to securing’ such comprehensive services. This apparently innocuous change of words will drive a coach and horses through universal provision. First, it prepares the ground for ending any powers of direction over any NHS body or provider. Second, it ends the duty on the health secretary to provide health services ‘throughout England to such extent as he considers necessary to meet all reasonable requirements’. Commissioning consortia will ‘arrange for’ the services necessary ‘to meet all reasonable requirements’ and determine which services are ‘appropriate as parts of the health service’. A consortium does not have a duty to provide a comprehensive range of services but only ‘such services or facilities as it considers appropriate’ – in other words, it will have discretion to define entitlement and to ration health care.
In making these arrangements, commissioning consortia must ensure that their annual expenditure does not exceed their aggregate financial allocation. The new NHS Commissioning Board has no powers of direction over defining the health services for which consortia will contract or over patient entitlements. It will be left up to health care multinationals.
Commissioning consortia will deliver services to an enrolled population which will not be defined geographically but through member GP patient lists. Practice boundaries may be abolished – a requirement if they are to be run by large multinationals – allowing patients to choose the consortium they wish to join, or for the consortium to choose the patient. Consortia have to provide emergency services for a defined area – but the position of someone who lives in the defined area and who is not enrolled in the relevant consortium is left unclear. It leaves the possibility open for people having to pay for emergency care and is certainly a threat to the elderly with their greater health care needs.
The Bill provides what is deemed to be a safety net: local authorities would become a provider of last resort – the Health Secretary can require councils to provide ‘services or facilities for the prevention, diagnosis and treatment of illness.’ As Pollock and Price argue, ‘Healthcare services that consortiums and market providers deem will threaten their financial viability can therefore be transferred out of the NHS in much the same way as long-term care and continuing care responsibilities were transferred out in 1996.’
Health care multinationals are going to run consortia and services and they expect to have sufficient guarantees for profit-making. We will be back to local authority poor law hospitals – a bog-standard level of care for the working class.
Not only is there no longer a duty to provide a universal service, but there is no longer any onus to provide free services, since the power under the 1988 Health and Medicines Act to impose charges is transferred from the secretary of state to the consortia which will determine which services are part of the health service and which are chargeable; they will have a general power to charge. There will be no formal mechanism for risk-sharing in relation to patients with complex conditions that are expensive to treat. Private companies that run the consortia are likely to establish referral centres to ensure referral and prescribing practices conform to budgets – already one such referral management scheme is in place in west London. These will operate according to the US ‘prior authorisation’ model – GPs will have to get approval before making any referral for further treatment.
One of the GPs who has been championing these changes is Charles Alessi, an executive member of the lobby group National Association of Primary Care. He expresses the utter inhumanity that will become the norm when these arrangements are put in place. Interviewed in The Guardian, he says that the NHS money has run out, and that in future, hospital doctors should be fined for prescribing unnecessary treatments. Who will define what these are? He claims that his local hospital carries out 20% too many hip and knee replacements; he says that too many elderly patients in his area are being given drugs that stop them going blind. ‘If you are overtreating some patients you are undertreating others.’ Asked if patients might revolt if they are not given the medicine they need, he replies ‘Yes, it is pretty uncomfortable, but we probably perform too many operations on people who should not have them’. This means the poor and elderly who cannot pay. He thinks it quite reasonable that if a hospital cannot afford to provide necessary treatments then people should move home: ‘In the future people may move for access to drugs. Patients already move to Scotland, which has free care for the elderly.’ So, if you need a hip or knee operation, get moving.
With GPs possibly set to double their personal income under the new arrangements – each GP setting up a commissioning consortium will be given a ‘management allowance’ of £55,000 with no rules about what it should be spent on – their opposition to the Bill has been feeble. A widely-reported meeting of doctors organised by the British Medical Association (BMA) to discuss the bill resolved to condemn it – but rejected calls for industrial action, defeated a motion of no confidence in Health Secretary Lansley and then instructed BMA representatives to continue their ‘constructive engagement’ with the government. There cannot be ‘con- structive engagement’ over this measure! You either keep the NHS as a universal free service or abolish it – there is no half-way house!
Even more repellently, Labour politicians responsible for accelerating the privatisation of the NHS and laying the basis for its destruction through PFI and other measures, voice opposition to the bill whilst in the pay of health care multinationals. Former Health Secretary Alan Milburn says he cannot support measures that fragment the NHS – although he was responsible for introducing the Independent Treatment Centres which did just that. He says that although he supports GPs having ‘ownership of the financial consequences of their clinical decisions’, he opposes the weakening of the public accountability, as if you could have one without the other. As 53,000 NHS jobs are shed to meet financial targets set by the last Labour government (savings of £20bn by 2013), we must be absolutely clear that Labour cleared the path for the dismantling of the NHS.
Hannah Caller and Robert Clough
Fight Racism! Fight Imperialism! 220 April/May 2011
