We believed David Cameron, when he said before the general election, that there would be no top down reorganisation of the NHS. After all, he had a son who needed care for many years – he wouldn’t lie about the NHS, would he? But shortly after the general election in 2010, a 360-page white paper was published that contained an unannounced plan to reorganise the NHS in every aspect, from the top down.
Where was the evidence that this top down reorganisation would improve patient care and be cost-effective? There was none, and opinion to the contrary has been suppressed. The transitional risk register still has not been published despite the Information Commissioner directing the government to do so.
Who told David Cameron that GPs wanted the NHS to run as a business, and that GPs would want to do it? GPs were not consulted, and both doctors and patients were told that they would be in the driving seat of decision-making and commissioning of services. This has proved to be untrue.
GPs are being forced into Clinical Commissioning Groups, organisations that live in trepidation of the National Commissioning Board. After all, the board has the power to withhold or withdraw their authorisation. CCGs walk a tightrope between best patient care, the security of local services and the implementation of government policy – at the same time as commissioning through competitive markets is to be made compulsory. If CCGs fall off the high wire, they can be sacked and the NCB will take back all powers, imposing a central solution. This exposes the farce of local decision-making and GP leadership.
If GPs were really expected to design local services, would Any Qualified Provider (AQP) be forced on to CCGs? Maybe GPs and patients would choose to use the money involved in tendering, contracting, accounting, monitoring and paying lawyers, to be spent on services instead.
Can GPs and patients choose the security of services from within the NHS rather than AQP? What happens when things go wrong? Who, but the NHS will pay for the mistakes of failed out-sourced services? The Southern Cross nursing home scandal is a salutory example. This was a business with secure income and filled beds, but it failed because of financial mismanagement. This example risks being repeated by providers across the NHS, who can withdraw from services if they are not profitable.
Another policy, personal health budgets, has been trumpeted as the solution to long-term care as it provides more choice for patients. The evidence is against PHBs as an effective way to deliver care, as highlighted by the Netherlands, where this system was stopped after 13 years.1 PHBs are to be rolled out in England from October, before the pilots have been reported on, and amid controversy about how the money has been spent. GPs, who know their patients well, advocate for them, and understand the patient experience of care, have not been asked whether this is an effective way to deliver care.
The Health and Social Care Act passed noisily through the Commons and the Lords in the face of opposition from doctors, nurses and patients. Some 140 Lords and many MPs with undeclared connections and financial interests to private health companies were allowed a vote. A select few GPs have been listened to, the few who were invited to the general practice summit at Downing Street in September 2011, to which the RCGP and BMA were not invited.
Finally, the BMA has come out in total opposition to the Act. But is its stance too little, too late? What can the BMA, GPs and patients do about the Act, given that CCGs are now entrenched in the roll-out of a competitive NHS?
The BMA will debate an initiative next month to enable patients to choose NHS over private providers. It is not too late; the Act requires secondary legislation that has not yet been passed. CCGs must show they listen to patients in their member practices. If GPs embrace this opt-out initiative, it will provide a starting point for dialogue with patients about the future of NHS care. GPs and CCGs will have patient support in commissioning of services that have been designed around the needs of the local population, not around private health profits.
We GPs must stop being conned. Do we want to be remembered as the generation that allowed the National Health Service to be destroyed?
Dr Coral Jones is a GP in Hackney.
References
1. Van Ginneken E, Groenewegen PP, McKee M. Personal healthcare budgets: what can England learn from the Netherlands? BMJ 2012; 3044 doi. http://www.bmj.com/content/344/bmj.e1383
