18 July 2010

A poisoned chalice?

The white paper euphemistically referring to liberating the NHS has made everything clear. The NHS as we know it is to be dismantled. In England anyway. Governments no longer want to be responsible for things. Career politicians want to be politicians. They want to give speeches and spin stories about their achievements. But they do not want to be responsible for running anything. When the NHS fails in some way they want it to be somebody else's fault. Governments have always been like this. They want to distance themselves from trouble. They want to blame others.

Looked at in this light Lansley's white paper is a master stroke. The health service will be delivered not by employees of the NHS but by employees of social enterprises. Lansley will create the largest social enterprise sector in the world. These organisations will deliver healthcare. They will do it for money. And they will make a profit. They will have the imprimatur of the NHS but they won't really be the NHS. Not, anyway, the NHS as it is now. That might sound pretty bad but you may not notice. Most people probably think their GP is an NHS doctor. The reality is that GPs are independent contractors. Patients don't notice so it clearly doesn't matter. It almost certainly has some advantages. GPs can actually be quite innovative and quick to respond to change.

In case it has escaped you, general practices are already social enterprises. They are independent. They work for money. They make a profit. Despite this anomaly many would say they are the jewels in the crown of the NHS. GPs are advocates for their patients. Patients trust them. They still provide the backbone of a cradle to the grave service. GPs know more than most about what their patients need. They have a sense of the sort of quality they want from organisations supplying those needs. They understand the crucial difference between needs and wants. And they have a good feel for the reputation of the suppliers of those needs.

The problem, of course, is that GPs are really just small businessman. They are small businessmen whose main interest is not in the business aspects of their social enterprise but in the good practice of medicine for the well-being of their patients. As things stand most of them have neither the time nor the inclination to commission NHS services on behalf of Andrew Lansley. Those in the know, an example would be Sir Richard Sykes, say they don't have the expertise either. But, frankly, neither did the previous incumbents.

Lansley's main aim has been met. Handing £70 billion of taxpayers' money to a bunch of independent commissioning amateurs distances the Con-Dem government from the NHS. It puts doctors in the driving seat which has been seen as being essential if change is to be effected. And it puts the blame for when things go wrong onto GPs.


Anonymous said...


Anonymous said...

I notice that discussion of this in the mainstream media has pretty well stopped. The public has clearly not caught on to what this really means, which is not surprising.

Dr Grumble said...

It is quite extraordinary how all this has happened without any genuine consultation or discussion. The economic crisis has been used as a fake justification for the strictures. That crisis stemmed from freeing the banks to operate in unfettered markets in a way that is not dissimilar to the 'liberation' of the NHS. The end result of the bankimg crisis was in some cases state ownership of the banks. Could it go full circle with the NHS too? Probably not. The family silver once sold is gone for ever.

My feeling is that quite a lot of the intelligent public do know what is going on but feel helpless to do anything about it. After all the three major parties in England have all been heading in the same direction. I wonder if Labour will regroup and go back to its old ideals to give the electorate real choice. There is a hint of that happening right now. We shall see.

6969 said...

Spot on. As a GP, I feel we are being stitched up with this one. It is more than likely that we'll have to get in outside help from the likes of McKinsey's/Humana etc. Once they've got their claws into this and effectively privatised the NHS, we'll take the blame if it goes nuts up! If it goes well, the politicos will take the credit.

gopher said...

If I were a GP I would be getting a group together to start talking to my local PCT commissioners now .. find a way forward and avoid bringing in the big private sector players. Better the devil you know?

Michael Gove was on the Today programme this morning saying how the 'debate' which took place during the election on schools policy was all that was needed therefore there is no need for further scrutiny of the legislation. Extraordinary view of how a democracy should be run - a bit of rabble rousing then push through legislation without debate. Didnt the 3rd Reich do something similar? - presumably they will take the same view of this.

As a non medic I am puzzled. Surely the BMA could put a spoke in all this now by just saying, 'we wont do it'. The fact that it hasn't suggests there are plenty of vested interests there who want the break up of the NHS, or can someone please enlighten me as to why we are not hearing from them?

Anonymous said...

Google 'Corkscrew Charlie' and 'stuffing their mouths with gold' and you find out how governments make things happen despite opposition.

Anonymous said...

Dr G,

You call it a "Con-Dem" government, which sounds very similar to "condemn". Was that deliberate or a Freudian slip?


Dr Grumble said...

It was copied from others, Neelu, so whether they intended the pun or not you will have to guess. Some might prefer Lib-Con which also has a hidden meaning

Doc Doc said...

Locally we have set up a commissioning group already so looking forward to being in control, rather than being dictated to by the local overbearing PCT.

One concern I do have is the conflict of interest if we financially benefit directly from lets say not referring patients to secondary care? How will the GMC interpret that?

Suppose it's no great difference from Fund Holding though!

Anonymous said...

Surely the only people who can put a stop to the proposed changes are the GPs themselves. However, if you read the GP rags, it appears a lot of them are FOR the White Paper, so it seems the changes will be made whether the public like it or not.

I think the proposed changes will make it even more difficult to trust one's GP. The financial motivations/incentives that underpin their clinical decision-making will come even more into question.

Anonymous said...

so our hospitals are going to be given away free to managers, how long i wonder before they award themselves huge pay rises, and maybe the prospect of personally profiting from the sale of ex NHS property ?

Dr Grumble said...

Like the civil servant creators of QinetiQ who made fortunes. John Chisholm banked a paper fortune of £26m.

The white paper says that foundation trusts won't be privatised but it does rather seem as if they may be given away.

Anonymous said...

The Lottery, Energy companies and QinetiQ and whatever next!!!

In 2007, the National Audit Office conducted an inquiry into the privatisation of QinetiQ to determine whether UK taxpayers got good value for money from the sale. The NAO inquiry looked at the following issues:
choice of privatisation strategy;
management of the process (the split of the Defence Evaluation and Research Agency into two, the sale to Carlyle and the flotation);
costs incurred and the proceeds achieved; and,
whether the deal met its objectives.[24]
In November 2007, the NAO reported that taxpayers could have gained "tens of millions" more and was critical of the incentive scheme given to QinetiQ managers, the 10 most senior of whom gained £107.5m on a total investment of £540,000 in the company's shares. The return of 19,990% on their investment was described as "excessive" by the NAO. The role of QinetiQ's management in negotiating terms with the Carlyle Group, while the private equity company was bidding for the business, was also criticised by the NAO. Carlyle bought a third of the business for £42m which grew in value to £372m in less than four years.


Dr Grumble said...

That's an excellent summary, Anon.

There is more on the sale of QinetiQ here.

Anne Marie said...

You may be surprised to learn that your view or OK general practice is very different to that of the editor of the Health Service Journal.
Or this may be no surprise at all.