As a GP for nearly 30 years and having worked through probably 13 “re-organisations” I have profound concerns about the Health and Social Care Bill1. The Bill, which had its Second Reading in the House of Commons on 31 January 2011, and proposes to radically reform the way the NHS is run in England.
Aspects of the Bill, such as the greater involvement of clinicians in planning and shaping NHS services, have the potential (if implemented well) to improve patient care and I welcome this. This alone has seduced many into thinking the Bill is a step in the right direction, but most professionals I speak to have changed their minds now more detail has been published. The benefits that clinician-led commissioning can bring are threatened by other parts of the Bill, particularly:
- Enforced competition: Forcing commissioners to tender contracts to any willing provider could destabilise local health economies and fragment care for patients. The doctors who are responsible for commissioning should be free to work with hospital and community care colleagues and patients to develop the care pathways that, in their clinical judgement, provide the best care for their patients, without fear of a challenge from the new NHS economic regulator, Monitor. Clauses 63 and 64 of the Bill would force consortia to open up services to competition that they have designed in co-operation with their secondary care colleagues. Commissioning is not shopping. The relationships we as GPs have with our consultant colleagues are essential to whether we refer patients to them. We do not refer to buildings but to people. The declared preference of Monitor’s new chairman David Bennett for chains of Tesco-style hospitals 2 exposes a sad and fundamental misunderstanding of how the sick should be cared for. Competition is of dubious cost benefit compared with the collaborative model of healthcare. It works when selling groceries, but when the grocery store fails food rots and people lose their jobs. It hasn’t been explained what happens when hospitals fail, which in the intended free market some inevitably will.
- Price competition: The Bill will allow providers and commissioners to agree prices below the tariff set by Monitor (to be paid for different sorts of treatments), opening the door to price competition. (This is clear in Clause 103 which states there will be maximum national tariff pricing). Such a move could allow some providers to chase the most profitable contracts, possibly using their size to undercut on price, which could ultimately damage local services. Every shred of evidence shows that price competition leads to a reduction in care quality 3. Ask any consumer of gas, electricity or user of the railways if they are happy and feel treated fairly (except the shareholders). Admittedly there has been some backtracking recently on this by Andrew Lansley, but this seems at odds with statements by Monitor’s Chairman.
But my other concerns and reasons for opposing the Bill are that it is
- Unnecessary: What is the problem the Government feels needs a massive revolution to fix ? The NHS has the highest approval rating ever. Mr Lansley’s main reason for introducing such untested change is that we have poorer health outcomes than, for instance, France. These claims have been largely discredited4-9. He persists with these false claims however as it exploits public fears in an effort to make more acceptable changes that would otherwise be regarded much more negatively . Myocardial Infarction rates are indeed higher at present but on the current trends UK death rates will be lower by next year. (And France spends 29% more on healthcare.) Rates fell faster than in any other European country between 1980 and 2006. Cancer death rates are also selectively quoted to suit his argument . If present trends continue the UK will have a lower breast cancer death rate than France in a few years. Lung cancer death rates are lower and there have been improvements in the 5 year survival rates of nearly all cancers.
If serious about “outcomes” Mr Lansley would do well to study the evidence from the UK and overseas that repeatedly shows that strong primary care produces better outcomes, better patient satisfaction and lower health costs.
The UK polled highest (93%) compared with European countries and the USA when asked about the ability to access a doctor on the same or next day , and when asked to rate the care they received from their regular doctors , the UK came second with 79% rating care as very good or excellent . But the gradual erosion of the GP as the first point of contact , together with current Government policy of more competition (under the guise of more patient choice) ignores this evidence Ironically , just at a time when GPs are to be given responsibility for large amounts of health service spend, our future as providers looks uncertain as competitors circle to compete against us. Around 300 million consultations take place annually in general practice with only 1 in 20 ending up with a referral to secondary care. 30-37% of patients in the USA are referred per year compared with 14% for UK patients12 . More reasons for avoiding heading in the American direction.
The budget deficit is used as an excuse too. Can I point out that this country was bankrupt after World War Two with a much bigger deficit and managed to create the NHS out of the rubble?
- Scale and pace of change: At a time of huge financial pressure, these major, untested reforms are, undoubtedly, a massive gamble. For instance rushing all hospitals to Foundation status could lead to a focus on achieving financial stability rather than maintaining high quality patient care. Boards of GP Consortia are being elected in some areas before GPs have had a chance to understand what is going on. Two recent polls10 have shown at least 60% of GPs against the Bill and more than 7 out of 10 disagree that “any willing provider” would improve health outcomes. We need to focus on enough excellent providers and not lots of any willing providers. Claims that GPs are falling over themselves to become Pathfinders is mischievous and devious. In our area, like most , a few enthusiasts are pushing ahead , and as it is compulsory , the rest of us are being dragged along. This allows Mr Lansley to claim ,falsely, that 252 GPs are keen, covering about 361,000 patients. By extrapolating this he arrives at his figure of 28.6 million patients already being covered by consortia, and by inference half the Country’s GPs . No wonder politicians are not trusted
The latest MORI poll 11 of all doctors reveals that 89% believe increased competition will lead to service fragmentation and 65% that it will reduce the quality of patient care , increase health inequalities and damage NHS values. 61% believe the reforms will lead to them spending less time with their patients. Current estimates of between 600-1500 full time equivalent GPs being removed from patient care to deal with the commissioning agenda will exacerbate the inverse care law that currently applies to GP provision—where areas of greatest need have less GPs per head of population. The Bill ignores this unfairness.
The risk is that the enthusiasts may think that they are championing the health needs of their patients when in fact what they are actually doing is sanitizing unacceptable decision making—such as the compulsory use of referral management centres , restricting patient access to specialist care and implementing stringent cuts in front line health care.
- No mandate: Andrew Lansley gave a pre-election pledge that there would be no major re-organisation , but the Head of the NHS Sir David Nicholson says this is so large it can be seen from space. It is disingenuous to claim it is in the Coalition Agreement—no-one voted for that. Furthermore, the Coalition Agreement promised “ to stop top-down re-organisation of the health service” This promise has clearly been broken and to give just one example where central control will remain is in the detail of the Bill where Ministers and the NHS Commissioning Board retain too much power over GP Consortia. There is not even any requirement in the Bill to consult with a Consortium or the public it serves if the regulators dissolve a Consortium Nor is there any recourse for appeal. So much for devolving power . The abolition of PCTs and SHAs appeared out of the blue months after the Coalition Agreement was signed.
- Inefficient and expensive : The Secretary of State’s claim is the reverse , but the health service still needs managing and many staff made redundant when PCTs and SHAs are abolished will need to be re-employed by GP consortia Furthermore the “market” will require a whole new army of bureaucrats economists ,lawyers and accountants. The biggest part of the Bill ( Part 3 amounting to 8 chapters) covers the red tape of economic regulation.
- Unfair: The logical result will be different levels of healthcare for populations in different areas , the creation and entrenchment of more so-called “post-code” lotteries , and ultimately a system where top-up insurance is needed for comprehensive health cover, thus producing, not a two tier , but a three tier service. As already mentioned , the Bill will exacerbate the inverse care law.
- Damage to the doctor-patient relationship: This is fundamental and one of my main worries. Few outside the profession really understand the problems created by the influence of money on clinical decision making. Many have the impression that “if it’s paid for, it must be better”. Nothing is further from the truth. Private medicine leads to over-investigation , over-treating, and more bureaucracy ,when often the best medicine is no medicine. Private care is measured by activity which is no measure of quality. At present the GP is still the patient’s advocate and most know that we are acting in their best interests. This will suffer if suspicions arise that investigations , treatments or referrals are not happening for financial, not clinical reasons. I feel rationing is being “dumped” on us as no political party has ever had the courage to tackle it. The cynic in me would claim that politicians rarely give up power voluntarily unless there is a benefit to them. The benefit they get is that they pass on a “poisoned chalice” The proposed “Quality Premium” rewarding for “effective financial management” is unethical.
- Confidentiality: The lack of safeguards for patient confidentiality needs to be addressed. The Bill gives broad powers to bodies such as the NHS Commissioning Board, the NHS Information Centre and the Health Secretary to obtain and disclose confidential patient information for a number of unspecified purposes. Fears that data may be shared with others may result in patients withholding important information. This may not only affect their health, but has implications for the wider health service.
- By failing to put in place proper safeguards, the government is potentially removing the control doctors and, most importantly, patients have over their confidential data. This conflicts with Government promises that patients will be given greater control over their medical records.
- Education and Training: At present training and workforce planning is organised regionally by SHAs, but with their abolition this will be commissioned by individual trusts. Workforce planning will suffer as it will be squeezed from the priority list by the necessary pre-occupation with day-to-day problems. The long term needs of the population will be relegated down the list. Trusts will no longer see the value of taking on doctors in their foundation year. Private sector providers will certainly not want to employ newly qualified doctors. There is a strong possibility that not all departments, or even whole trusts, will be training units. The current proposals suggest that such decisions may well be made for business rather than educational reasons.
- Commercialising healthcare is bad for health - both for the individual and community. There is no evidence at all that private companies are more efficient or lead to better outcomes. There are some good local examples where “outsourcing” (often the euphemism for privatisation) has produced a service for patients that can only be described as pathetic (for example counselling and cataract services. The former “ticked it’s contract boxes” and was able to claim that it had dealt with a referral by ringing patients and telling them to buy a book from Waterstone’s! They “cherry-picked” refusing to see certain well-deserving patients in need. The Cataract service disappeared overnight, abandoning patients). When the public wake up to the extent that shareholders are making profits out of healthcare at the expense of the taxpayer and in principle this differs little morally from bankers taking home large bonuses from the public purse, there will be a tidal wave of anger . Too many politicians, including several former Secretaries of State for Health, have links with private healthcare providers Most of these companies have no experience of UK general practice, but a lot of experience of making money.
The Bill will have the most significant impact on the future of NHS services, its workforce, and public health. Eventually, whether the intention or not, a state monopoly will be replaced by a corporate cartel big enough to bully parliament and suffocate true competition. The food industry is analogous, with a handful of large companies monopolising and dictating, delivering some of the highest prices in Europe.
I believe the way a society delivers it’s healthcare defines the values and nature of that society. The NHS is extremely popular with the British public, and I feel these reforms will destroy a 63 year old National treasure against the wishes of the vast majority. Scotland and Wales have woken up to this and got rid of the market and the English need to be alerted to this danger . The “National” will no longer be an appropriate initial in the title NHS, but even worse, the H for health will be replaced by a B for business. In the USA, healthcare is not primarily about looking after the Nation’s health, but a huge multi-company money-making machine. That defines their society. The USA pays twice as much yet lags behind other wealthy nations in such measures as infant mortality and life expectancy where it stands 48th in the World. More money is spent per person on healthcare than in any other nation. The World Health Organisation has ranked the US healthcare system as the highest in cost, 37th in overall performance and 72nd by overall level of health amongst the 191 member nations surveyed. As Mr Lansley is so keen to justify his revolution on the basis of health “outcomes” he should take note of these particular outcomes before dragging England towards an American style healthcare system. The contrast is of a caring society which looks after the weakest and sickest with a dog-eat-dog survival of the fittest, where money rules.
It is not exaggerating to have a nightmare vision of the future in which corporate business interests will be given or get incentives to select patients, time limit care, sell top up insurance and introduce charges for some elements of care no longer provided by NHS. As Government pushes it’s competition message harder, it will make practices compete for members (formerly known as patients) just like US health insurers.
This is a chilling prospect for the elderly, those with chronic illness, people with mental illness and long-term needs who are of no commercial interest to these corporations .
If this Bill is not defeated, or at least radically altered, we are likely to see the NHS killed off . This will either be deliberate i.e. for idealogical reasons, or accidental by short-sighted ignorant here-today-gone-tomorrow politicians . Either way it will no longer exist, the Country will be worse off , patients will suffer and there will be no going back.
Dr Paul Hobday MBBS FRCGP DRCOG DFFP DPM
1. Open letter to Mr Lansley Kent Messenger 18/2/2011
2. Times Interview 25/2/2011
3. Studies by The King’s Fund , LSE , OECD
4. BMJ 27/1/2011 John Appleby Vol 342 p566
5. Organisation for Economic Cooperation and Development. Health data 2010—October. www.ecosante.org/index2.php?base=OCDE&langs=ENG&langh=ENG&ref=YES&sessionid=c16dc593ee04af1d45405b93ebff734e/.
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10. Royal College of GPs 1/2/11 and Pulse 18/1/2011
11. Ipsos MORI 1/3/11
12. Forest C , Majeed A et al BMJ 2002; 325:370-1