In recent weeks, the government's plans for reforming the NHS have come under increasing pressure from Labour, the BMA and most recently, the RCN passed a vote of no confidence in Andrew Lansley's management of the bill by 96%. This has forced the government to take up its 'listening exercise' while the bill sits in the middle of the law making process in Parliament. So are the reforms (which is the largest in the NHS's history since its creation) an application of free-market principles as its critics argue or is it another 'difficult but necessary' consequence of deficit reduction?
The government's 'listening exercise' came under heavy fire, even as it took its first tentative steps with a joint press conference of the PM, deputy PM and the Health Secretary. It was accussed of being just another PR exercise, typical of a Prime Minister who thinks his delivery rather than substance is failing (as labour supporters claim). Andy Burnham, the former health secretary claimed just that, and Ed Miliband looked to step up the pressure by calling for the reforms to be completely 'junked'. Ignoring this cheap choice of word, it has become common place these todays to expect no less from the leader of the opposition who continues to fail to provide any alternative, let alone constructive criticism. Similarly, as Labour's election coordinator, Andy Burham's comments seem symmetrically, strategically placed, not to save the policy from its flaws, but to contribute to its sabotage. Having burnt off this fog of partisan presentation which seems to blur all mediums of policy communication and reporting, I can turn to the more serious task of the debate over substance....
As in all other areas of policy, the government's plans were founded in the argument over the national deficit and government plans to emilinate the structural deficit of the state by 2015. Quite simply, the NHS is operating in the economic circumstances of the previous decade where it could afford to suffer from the inefficiencies which plague it thanks to Labour commmitments of large-scale investment and funding. Today, the NHS's ineffeciences are neither sustainable nor economically acceptable. To combat this the governments plans propose to move the responsibility to commission services and therefore control the NHS budget from Primary Care Trusts (PCT's) to GP Consortia. Firstly, this will make savings by removing the PCTs as a management level entirely and moving their role as commissioners to GP Consortia, the very practicioners who are meant to be most in touch with public concerns over care. Secondly, the government is trying to cut out inefficiencies in the large acute trusts (hospitals) by opening up the commissioning of services to all service providers including private and volunteer companies. This means acute trusts can become centres which specialise in emergency or unplanned care and no longer provide the more simple planned care routes for which there is a far greater demand and which it provides so inefficiently, therefore saving the NHS money. This solutions appears both logical and credible.
However, critics including Mr Miliband argue this process is against the values embedded in the NHS since its creation. On the 4th April while addressing the RSA, Ed Miliband claimed of the Health and Social Care Bill, 'on grounds that it doesn’t meet the challenges of the future, that it weakens rather than strengthens accountability and that it threatens the ethos of the health service, these changes are simply wrong.' His first contention is really a technical point in which he is simply reflecting that David Cameron's plans are more economically driven than in the interests of reforming healthcare to deal with future challenges, a key platform on which he is basing his reforms. This is true because, as lobbyists for the acute trusts have argued, private providers will 'cherry pick' services which have relatively cheap costs, receive higher demand and has larger profit margins. Therefore they are unlikely to provide the more major and serious services which attend to the changing needs of an ageing population. His second point about accountability plays on the fact that there will be a conflict of interest in the new structuring system where GPs are both commissioners and service providers. Thus, they are likely to have vested interests in where the money goes. Finally, he makes a symbolic point that the apparent 'privatisation' of the NHS is against the 'ethos' and values upon which the NHS has been guarded since its creation. Rather than seeking out an internal solution, he remarks that David Cameron has simply turned to the free market for a solution which will jeopardise the position and symbolic significance of the NHS in the public's eyes, in the nations identity and for every government to come.
Although the claim of privatisation is rather weakened by the fact that the costs of a service will continue not be determined by the provider but by the commissioner (which retains the principle of selection by quality rather than cost, as acute trust representatives maintain), a larger proportion of healthcare provided in this country will come from private companies. More ideologically important to Mr Miliband and representatives of acute trusts (all those who work in hospitals), private companies will reap profits from the taxpayer whereas, under previous NHS providers, all profits would have been reinvested within the acute trusts, a sour point for all who respect and value the principles of the NHS. Ultimately, despite all these criticisms, the point remains that we can no longer afford an NHS ridden with such inefficiences. Very much like Mrs Thatcher before him, Mr Cameron has decided this failing industry cannot be subsidised just because of the symbolic importance it holds in the minds of the nation, the free market must reign. And for all his just criticism, Mr Miliband has been unable to provide an alternative idea let alone a viable solution. Sticking to his ideological guns he will continue to hold the position that these 'cuts' are threatening frontline services and most importantly: jobs. So, politically, the debate returns to the age old partisan question: is unemployment a cost worth paying? Even if this 'listening exercise' is just a PR stunt, we know who holds power and we know who will say yes.
Lol alex. What are the arguments for deficit reduction at the rates currently being pushed through by the condemnation?
ReplyDeletelol matt...i think their main arguments (as i describe above) on this issue sit with the acute trusts:
ReplyDelete1)That the 'privatisation' of the NHS will create a system of service provider selection by cost and not quality.
2)That the reforms will allow private companies to 'cherry pick' which services to apply for in order that they can maximise their own profits on the payment of taxpayer money.
3)That introducing more privatised service providers will further weaken the accountability of the NHS, alongside the conflict of interest that GPs will be under from being both service commissioners and providers.
4)That the reforms actually open up the NHS to prosecution under European competition laws.
5) And finally, that opening the NHS up to private providers will not only put frontline jobs at risk but will be against the established values of the NHS adn therefore, damage its public image within the antional identity. (rather conservative point that last one)
I think much of the inefficiency within the NHS could be sorted out by 'de-politicisation' and better (not non-existent) management.
ReplyDeleteThere have been vast amounts of money wasted by ill thought-out politically driven schemes (Private Finance Initiative (PFI) hospitals, walk-in clinics, NHS Direct, 'nurse’ practitioners, the Medical Training Application Service (MTAS) to name a few) which cost a vast amount of money only to not deliver in real terms. This is very trying for the people on the ground, who could have told you that it wouldn't work in the first place and resent the increasingly nonsensical demands on their time and resources that get in the way of good clinical care. The NHS actually very much runs on the goodwill of a lot of its staff, and if you consistently treat them as if they and their opinions don't matter then the resulting loss in morale is very negative for clinical care and efficiency. There is much good in the NHS, and though there are problems too it is important that the good is valued and maintained whilst complex issues are gradually addressed in a considered way.
I believe that it is a myth that including private services in the NHS will provide more efficient clinical care. The bottom-line of a private company is to generate profit but good clinical care is not necessarily profitable. Similar arguments are applicable to competition within the NHS. Private hospitals probably do operate more efficiently than NHS hospitals: they have less complex demands on them; clinical staff often get higher pay, and their pay and other rewards is often more directly linked to throughput; and the companies need to provide a certain level of service in order to attract patients to use them. But when private companies provide services within the NHS it can vastly increase inefficiency: the purchaser is no longer the patient but the NHS managers, who may not always properly understand or choose value for money in a clinical context. PFI hospitals provide good examples of this. I have worked in several, and although they may look glossy from the outside, the NHS pays large amounts of money to companies that often provide a substandard service and the structure and hierarchy of teams becomes disrupted. Patients, visitors and staff have to pay high prices for food, parking etc., the profits of which do not go back into improving the hospital but to a private company.
To be continued...
Alec,
ReplyDeleteContinued...
I don’t believe that handing managerial power to clinicians is necessarily the answer: management and clinical care are not mutually inclusive skills; clinicians often see their area of practice or enthusiasm as most important and may not always see the wider picture; management takes clinicians away from clinical work, and may actually attract those who aren't as comfortable with clinical work. What is needed are managers that will take time to get down on the 'shop-floor' to listen and understand what is going on before making decisions that balance all the competing concerns. They also need to be transparent and accountable in their decisions. And while it is imperative that views of others are listened to and considered, managers need to be decisive, reactive and flexible. Currently NHS management relies on a tangle of business proposals and committees to make their decisions and are very poor at genuinely engaging with the frontline situation. Clinical staff e.g. doctors, nurses, technicians do not have the expertise or time to draw up proposals, and committees tend to lead to inaction rather than action, or actions that are so delayed that the situation has changed significantly from that on which the decision was based.
Another interesting fact about private facilities versus NHS is their view on value for money. NHS trusts seem very vulnerable to agreeing to contracts with private companies that take them for a ride in terms of value for money, and are poor at penalising these companies for poor performance. NHS purchasing often focuses on cheapness, which is often not the same as cost efficiency; or goes the other way, and goes for flashy, exciting equipment (often the 'baby' of some enthusiastic clinicians). Not that this equipment is necessarily useless, it may have lot of benefits, but a limited budget requires appropriate prioritisation.
Alec,
ReplyDeleteContinued...
Lastly, I would say that NHS systems actually produce disincentives to efficiency. In private hospitals (I think, as I am too junior to do private work myself), there are a certain number of patients per operating list, and staff are paid per patient and finish when the list is finished. In the NHS, the lists run for an allotted time, and if you are efficient and get through your workload then you will get more work loaded upon you, whereas the less efficient lists won't i.e. there is a negative incentive to be efficient.