The NHS has been the main concern of voters heading into the general election. It has also become a political football punted across the green benches. Labour accuses the Conservatives of privatisation. The Conservatives fling back the accusation that Labour is ‘weaponising’ the NHS. Pundits, politicos and pub bores – everyone is pontificating on the future of the NHS.
We keep hearing about broken promises on the NHS: namely the Conservative manifesto promise of no more top-down reorganisation from Whitehall prior to the massive overhaul of the Health and Social Care Act.
But the great irony is that the Health and Social Care Act will guarantee exactly this – no more top down reorganisations. It is effectively self-perpetuating. It devolves responsibility for the health service to a number of bodies, such as NHS England and Clinical Commissioning Groups, at arm’s length from Whitehall. A key part of the Conservative policy of denationalisation is abolishing day to day government responsibility for the NHS. The Manchester devolution of health and social care funding is likely to be the first experiment of many.
CCGs are only legally obliged to provide limited services, such as emergency care and ambulances – much reduced compared to the remit of Primary Care Trusts (PCTs) to provide listed services. The rest is up to them or as the corporate legalese puts it – what they deem to be “appropriate as part of the health service”. But the funding constraints imposed on CCGs will leave them between a rock and a hard place. Rationing has always been a feature of the NHS but now, Devon CCG for example has axed routine surgery for obese patients and smokers and routine shoulder surgery has been restricted for all patients. Being modelled on US accountable or managed care organisations, CCGs should be viewed as insurance pools, which will increasingly exclude the poorest and sickest from coverage.
NHS contracts are forced open by compulsory competitive tendering to Any Qualified Provider amongst other mechanisms. But ‘cherry-picking’ of services that are cheap or cost-effective to run leads to ‘unbundling’(investing the surplus from routine services into complex healthcare), undermining the fundamental principles of the NHS.
The chronic under-investment and under-funding in general practice, combined with potential cuts to tariffs in deprived areas, means that federated GP organisations will attract private investors and corporations.
Integrated care, supported by Labour, will mean hospital services moving into the community. However, this will dovetail with a massive hospital closure programme.
At the same time, personal health budgets (PHBs) are being rolled out to 10,000 patients with complex needs. (It is projected that five million patients will use PHBs by 2018)., This will introduce the need for top-up payments or co-payments from patients taking part – which will likely lead to the integration of care pathways and packages with healthcare insurance.
As CCGs increasingly commission care from private providers with the NHS budget, in effect the NHS will move from being a state deliverer to a state insurer along the lines of Medicare in the US.
Meanwhile, more patients will have personal health budgets, supplemented by co-payments and insurance in the future, thus making them self-paying consumers in a market-based healthcare system.
Of course it doesn’t have to be this way. A lot depends on who wins the election, and on unrelenting pressure from the BMA, Royal Colleges, medical bodies and campaign groups.
Contrary to the argument cited by those pursuing a reform agenda, the NHS is extremely cost-effective. We spend significantly less than comparative EU countries and half what the US does. Markets in healthcare increase costs and reduce efficiency. The NHS performs well according to the Commonwealth Fund – which rates it as the best in the world – and the OECD. The British public is overwhelmingly in favour of a public NHS. The simple truth is that planned healthcare systems are superior.
In fact, many of the problems in the NHS are generated by markets. Reversing the 30-year journey of privatisation as well as ensuring that the NHS receives sufficient funding would relieve much of the pressure on the system.
If the parties mean what they say about valuing a public NHS then they need to pass the NHS Reinstatement Bill 2015 presently in front of Parliament and ensure it is on the Queen’s Speech.
Youssef El-Gingihy is a GP and author of How to Dismantle the NHS in 10 Easy Steps, published in July by Zero Books. He tweets @ElGingihy.