By Anna Athow, Consultant Surgeon
‘WE HAVE reached crunch point, where the process of transition from one system to another is taking place.’ So said Prime Minister Tony Blair on April 18, 2006. He referred to the advent of ‘practice based commissioning’ (PBC), ‘payment by results’ (PBR), ‘patient choice’ and ‘private providers’.
What are the two systems?
What we had was public funding and predominantly public provision.
The new system is public funding and predominantly private corporate provision.
Professor Ham, erstwhile Director of Strategy in the Department of Health (DoH), describes the new system as follows: ‘The foundations have been laid for the complete transformation of healthcare delivery.
‘We are shifting away from an integrated system, in which the NHS provided virtually all the care, to a much more mixed one, in which the private sector will play an increasingly major part.
‘The government has started down a road which will see the NHS increasingly become a health insurer.’
Private corporations are in a hurry to get the contracts.
When leading businessmen from Tesco, BMW, Cable and Wireless and other FTSE 100 companies and chief executives of foundation trusts met Blair on June 6, they called for the sacking of thousands of ‘Luddite’ hospital managers if they refused to make cuts and embrace the ‘reforms’.
The Kings Fund, a pro-government think-tank, expressed their views, when its June 5, report called for ‘no arbitrary limit to the role of private or independent providers’. They were not happy with a 15 per cent limit to private provision. They want a 100 per cent.
The NHS is at the cross roads.
It started out with a revolutionary method of health provision in 1948, whereby the jumble of voluntary, Poor Law and fever hospitals were nationalised into one collaborative network.
Community care was provided through local authorities and GPs – as private contractors, but with a special non-profit remit – had a contract with the state to provide primary care.
Because funding was by taxation, according to ability to pay, and was redistributed according to clinical need through a large risk pool, it was possible to provide comprehensive care for every citizen, free at the point of use.
It took away the fear of falling ill if you were poor and provided high-quality care, with access to consultant care if needed.
The system has been privatised bit by bit since then. Charges for opticians, dental care and prescriptions were soon introduced.
Major privatisation reforms in the Tory Thatcher years included Griffiths management, the purchaser-provider split and hospital trusts.
‘New’ Labour accelerated the process with the concordat with the private sector in the NHS plan 2000, actualising the Tory plan for building new hospitals and health centres with Private Finance Initiative (PFI) schemes and Local Infrastructure Finance Trusts (LIFTS).
The return of the purchaser-provider split, in 2003, set up primary care trusts (PCTs), which opened the door for commissioning clinical services from corporate private providers.
PBR, independent sector treatment centres (ISTCs), foundation trusts as commercial businesses, ‘choice’ and practice-based commissioning (PBC) then followed and now stand poised to open up a market in health care, where competition will destroy providers which cannot make a surplus at tariff.
The privatisation of Community Care has been announced and PCTs must divest themselves of direct provision.
The government talks of crunch time as it prepares to deliver the killer blow to NHS hospitals and traditional general practice which is at the heart of NHS clinical services.
They are doing it two ways.
Firstly, £1.2bn direct cuts are being used to physically obliterate NHS facilities, sack nurses, disband clinical teams, close down wards, operating theatres, beds, Accident and Emergency (A&E) departments and whole hospitals.
District general hospitals (DGHs) are to be ‘reconfigured’ out of existence by removing critical services like paediatrics, A&E and emergency surgery, making them non-viable as discrete comprehensive clinical entities, and removing teaching status and junior trainees.
Secondly, by implementing the January 2006 White Paper on healthcare outside hospitals, ‘Our Health, Our Care, Our Say’, with no discussion.
The White Paper dictates:
* the continuation of funding cuts to NHS hospitals.
* The transfer of £4bn from NHS hospitals to ‘Community Care’ per year for 10 years.
* The unbundling of hospital care pathways so that the profitable bits – diagnostics, outpatients, stepdown care and day surgery – are transferred to polyclinics, new community hospitals built by multinationals serving a 100,000 population.
* That PCTs must preferentially tender to private corporate providers to set up health centres competing with traditional GPs.
* That PCTs must give up their commissioning role and outsource it to private corporations.
* The extension of PBC so that GPs are incentivised not to refer patients to hospital. This, coupled with demand management are already denying patients the right to consultant care.
* Long-term health and social care amalgamation, such that charges can be introduced for healthcare. Indeed Blair refers to patients as ‘customers’.
Not discussed, or voted on, in Parliament, it is being put into practice right now.
Private corporations are taking over GP services. We have seen this recently with the PCT handing of the contract for Creswell Primary Care Centre, in Derbyshire, to United Health and in Barking, Essex, to Care Company.
The Financial Times, last week, described the implementation of the final piece of the privatisation plan, the outsourcing of PCT commissioning to the private sector, as ‘The last brick in the wall’.
It reported: ‘Private health insurers are being invited to take over the purchasing of care for NHS patients . . .
‘The move is likely to attract interest from big US insurers and providers such as United Health and Kaiser Permanente, Discovery of South Africa, BUPA, PPP and Norwich Union in the UK, and possibly German and Dutch health insurance funds.’
The government is proceeding to hand over to the corporate private sector the 80 per cent of NHS money that the PCTs receive to commission care. In this way private corporations can commission care from themselves.
The logical endpoint is the NHS as a brand logo over a group of corporate chains.
Some say this will make no difference to care and that it does not matter who provides the care. This could not be further from the truth.
Care will no longer be universal or comprehensive. It will not be free at the point of use.
The working poor will not be able to afford healthcare. The situation will be similar to that in the US, where 40 million patients have no health cover.
Charges: The government intends cutting the funding to 1997 levels in 2008. Then the corporations will charge.
Queen Charlottes Hospital Trust charges £4,000 for personal midwifery.
Charges for car parks, telephones, TVs, and drugs in day surgery have been introduced.
Hospital hotel charges of £5 per day are being contemplated.
Billions of NHS funding has been wasted on these private ventures, that have resulted in reductions of care, inferior care, no care, and charging for care.
The BMA leadership policy is to accept the reforms. (see HPERU Briefing Paper, June 2006, and ‘Ten points to clarify system reform’, BMA 19.4.06.)
They call for more PBC, using PBR to incentivise doctors financially, ‘a level playing field’, a strategy for failing systems, more clinical involvement with managers and with the reforms, unbundling of pathways.
They express disdain for ‘ill informed knee-jerk reactions’ and ‘banner-based debate’.
The vast majority of doctors support the NHS and want to continue working in a publicly-funded and provided NHS, providing comprehensive care for all on the basis of clinical need, free at the point of use.
Doctors and all NHS staff value permanent employment, NHS training, national terms and conditions and NHS pensions.
The first casualties of the reforms are staff; 15,000 nursing posts have gone, International Medical Graduates are being sent home and 11,000 SHOs have no hospital training posts to go to.
Consultants and GPs will quickly follow.
The NHS can only be maintained if block funding is restored to NHS hospitals, the reforms are reversed and the private healthcare corporations are kept out.
This means opposing the government.
We need a leadership that is prepared to stand up to it and adopt a policy to defend the NHS.
Because the government is using blitzkrieg methods to establish ‘facts on the ground’, action needs to be organised immediately to stop service closures and job cuts.
Doctors need to link up with other health service unions and other public sector staff facing similar privatisations.
To start with, we need a day of action which would include supportive industrial action by TUC-affiliated unions.
It must be made clear to this government, that they have no right to privatise our NHS, and will not be allowed to do it.
It is not the NHS that must go, it is those who want to destroy it.
Doctors must join with ‘banner waving’ patients, the RCN and the TUC organised trade unions to take action to stop the privatisation of the NHS. That this will mean bringing down the Blair government and bringing in a socialist government is obvious.