13 October 2012

How the NHS was lost

Here is a recent editorial by Jacky Davis for the NHS Consultants' Association newsletter:

We really ought to have a black border around the latest edition of the Newsletter, to mark the death of the UK National Health Service. After a 2 year fight, the infamous Health and Social Care Bill finally became law earlier this year. The legislation was bulldozed through parliament with the assistance of the Liberal Democrats, a scandalous betrayal which will not be forgotten or forgiven. In its final stages it was encumbered with over a thousand amendments and is now even more Byzantine and dangerous than when it first saw the light of day. It was opposed by every major organization representing health care workers and degenerated from a bill sold as empowering doctors and patients to one battling the vested interests of the professionals. Its passage was a low point for democracy in this country. It became a matter of political pride and personal prestige, an arm wrestling match in which the coalition leadership had invested too much to back down. 

It’s worth recalling why it matters so much. This legislation is a bottle of snake oil, it doesn’t do anything it promises on the label. Cuts costs? No, costs will rise, with the ever increasing financial burden of marketised care not to mention £3 billion+ for the ‘reforms’ themselves. Cuts bureaucracy? No, it replaces 3 layers with 7 and the CEO of the NHS Confederation has recently warned of a ‘tsunami of bureaucracy’. Gives power to patients? No, patients will have less choice than ever thanks to management referral centres, reduced treatments, and the limited choice already present in some parts of the country where the private sector has taken over. 

It certainly doesn’t give power to doctors and front line staff. GPs will be answering to CSUs run by private companies and in London GPs have already been forced to pay for commissioning ‘support’ from the private sector. Management consultants like McKinsey have made millions so far and are anticipating many more millions to come. At the same time GPs are taking the blame for massive cuts in budget and we are already seeing headlines blaming doctors for service cuts and for denying care to patients.

Finally it cannot fail to adversely affect teaching and training, core functions of the NHS. No wonder the government defied the law and refused to release the risk register. 

So the H&SC Act represents a massive redisorganisation of the service, so huge that according to the Big Beast himself, Sir David Nicholson (CEO of the NHS) it could be seen from outer space. How was it possible that such unwanted, undemocratic and destructive legislation could get through against the opposition of the profession? Part of the answer must be that there was a dreadful failure of medical leadership and much of the blame lies at the door of our representative bodies. 

Many GPs were unfortunately but understandably attracted by the idea of commissioning while failing to notice that it came accompanied by less attractive elements including the drive to outsource any and all NHS services to the private sector. The BMA, with GPs in the driving seat, pronounce the bill to be a ‘curate’s egg’, good in parts and announced that they would have the tasty bits and manage the rest, thus fatally missing the point of the tale of the curate’s egg. Once part of the egg is rotten the whole thing is inedible and this is as true for the HSCB. It is woven of whole cloth, without the possibility of taking up the attractive parts (if indeed there ever were any) while rejecting the rest. 
The BMA failed to consult its members over the HSCB, relied too heavily on political lobbying for ‘significant amendments’ which never materialised and resisted coming out in opposition to the bill until forced to by repeated emergency motions at Council. By then it was too late, and on the day the bill became law Andrew Lansley was still claiming that he had the support of the profession. 

The Royal Colleges, with a couple of honourable exceptions, were the dog that didn’t bark in the night. Not a sound was heard from most of them on a matter which would massively affect their members. They kept their heads down, discussing instead (in the case of my own college) important matters such as the move to a new building rather than legislation which would affect every aspect of their remit i.e. teaching, training and standards. 

Finally in desperation at their silence several campaigners, led by David Wrigley, a GP from Cumbria, set up a website to encourage college members to formally request emergency meetings of their college so that they could call for opposition. The resistance of college officials to this move was a sight to behold, and many interesting conversations took place with people to whom it had clearly never occurred that the members might notice what was going on (or not going on ) at college HQ, and what’s more might have the temerity to question it. I’ll forever treasure the memory of a phone call to someone at the RCS to say that we had enough members signed up to call for an emergency meeting. ‘But I’ve never heard of you’ was the bad tempered response. Well you have now and what’s more we have the requisite number of names to request a meeting. The great and the good who represent us did not appreciate being called to account. 

Once called to account almost all the colleges found themselves faced with overwhelming demands for opposition to the bill from their members. Even then there were delaying tactics but the message had gone out to the media that doctors were united in their opposition to the legislation. Unfortunately by then it was too late to stop the bill. 
A shining exception to this behaviour was the RCGP, which regularly consulted its members and whose president, Clare Gerada spoke repeatedly about her concerns. Given the supine position of the rest this was a heroic thing to do, and attracted a lot of press coverage. Many firmly believe that if the whole medical establishment had had the courage to work together and speak out against the bill it could never have survived the joint onslaught of the profession. As it was the complicit enablers, through silence or, even worse, co-operation, betrayed the NHS, the profession and our patients. Shame on them, history will not remember them kindly. 

So are the prophets of doom right, and is the NHS in England facing extinction? Well, the news coming in is not good and already we are seeing the vultures circling the NHS. Significant contracts have already gone to transnational corporations like Virgin and Serco, the biggest company you have never heard of. Virgin picked up community services in Surrey, where presumably patient choice now consists of Virgin or Virgin, and also ‘integrated children’s services’ in Devon. As far as I know they have no experience of providing the latter but that doesn’t seem to matter in the brave new world of outsourcing public services. The core business of these transnational companies is in winning government contracts regardless of what they are for. They have the experience, the legal expertise, and the deep pockets to allow loss leaders if necessary and it is simply unrealistic to think that small charities and social enterprises can take on these huge companies and win. 

Once they have the contract they then put together the package, and the word is out that community paediatricians are being urgently sought, presumably to fulfil Virgin’s new contract in Devon. It has been said that G4S, awarded the security contract for the Olympics, expected to take on operatives and deploy them 3 days later. This is no way to run any public service let alone the NHS and the G4S Olympic fiasco certainly seems to have alerted at least some in government to the dangers of outsourcing public services. Vital public services like the NHS can’t just simply be allowed to disappear, and if private providers fail or walk away when profits don’t materialise then the government has to step in. The result is that profits are privatised while risk is socialised, a convenient scenario for the private sector but a recipe for disaster for the tax payer, the NHS and those who rely on it.

Elsewhere GPs are waking up to the real world of loss of autonomy to the Commissioning Board and to commissioning support services, which are likely to end up in the hands of – you’ve guessed – the private sector. At what stage will GPs decide that they can no longer ride the tiger of the HSC Act and that it would be better to show their disapproval with events by walking away from commissioning? There are still those who argue that they must remain involved otherwise ‘others will do it’ but that is the primrose path to hell. We underestimate our strength as a profession, but strength requires acting in unison which requires strong leadership. We are still waiting for it. 

Meanwhile the ‘Nicholson challenge’ of ‘saving’ £20 billion makes a nonsense of promises that there would be no cuts to NHS services, and thousands of front line jobs have been lost already. And as longer and longer lists of treatments are excluded from the NHS menu as part of these McKinsey-driven “efficiency savings” fewer people will be offered an acceptable choice; instead many will have to choose between pain and discomfort or paying privately. Personal health budgets (PHBs) are another ideological move, designed to facilitate the path to top ups and co-payments while allowing top slicing by 20% to cope with the financial constraints. Martin McKee’s article in the BMJ described how the Dutch are moving away from PHBs while we are rushing to embrace them – yet another example of policy based evidence making? 

There are too many other depressing stories related to the cuts and the ‘reforms’ to describe them all but you might like to consider that criminals can now run the NHS that NHS patients will be able to ‘self fund’, the role of the media during the listening pause, predictions about the privatisation of hospitals, how patients lost their sight at a private centre, and the scandal of over treatment in the USA to chose but a few. And if you want more where those came from please follow Clive (@clivepeedell), myself (@DrJackyDavis) and KONP (@keepnhspublic) on Twitter. People who don’t tweet often think that it is just about what Wayne Rooney did last night but if you ignore the celebrity trivia it is a wonderful campaigning tool. Depending on who you follow you can get all the news, articles and low down on health and medical politics and never need know what Madonna had for breakfast. Try it, you’ll be pleasantly surprised, but - health warning – it is dangerously addictive. 

On an up note the Olympics provided some great bread and circuses entertainment and Danny Boyle became an instant NHS hero when he featured the NHS during the opening ceremony. Needless to say Tory MPs immediately saw a conspiracy, but most recognised a genuine wish to celebrate one of this country’s greatest institutions, even while we are in danger of losing it. 

Talking about great institutions and sporting achievements, the award of Hero of the Year goes to my Co Chair Clive who distinguished himself by running from Nye Bevan’s statue in Cardiff to the DoH in London, an unbelievable feat which required 6 marathons in 6 days. We salute him and his running partner Dr David Wilson both of whom spent a great deal of time in ice baths, although with or without added gin and tonic is not reported. They were helped along the way by the indefatigable Chris Burns Cox who provided transport, logistical support (and possibly the gin). Read about it here. Hypocrite of the Year award was a difficult decision as ever but probably goes to the Coalition government for rubbishing the NHS at home while selling its brand abroad. But there were plenty of other contenders for the title. 

The year has been a busy one for your officers, with many public talks, articles, letters in the paper and arm wrestling with more conservative institutions. Thanks go as ever to our equally indefatigable president Peter Fisher, without whom the organisation would not survive let alone prosper, and to you, our members, whose subs allow us to help our sister organisations KONP and the NHS Support Federation in their important campaigning work. More members mean more money and perhaps if you do one thing to help the NHSCA in the next year it should be recruiting at least 2 new members. And meanwhile be thankful you’re not running 6 marathons... 

A pdf of this article with the references can be found here.


Cockroach Catcher said...

Welcome back!

Northern Doc said...

Good to see you back. Hope this won't be an isolated post and that more original material will follow.

Some friends up North.

hyperCRYPTICal said...

Yippee! You're back!

Eeek said...

Welcome back

Julie said...

Hurray! You're... well, what everyone else said. Suddenly the blogosphere looks brighter..

Dr Grumble said...

Thank you all. No pressure then‽

Christopher Slater-Walker said...

Well I really have to wonder exactly how much opposition GPs have to the changes; apparently many of them have vested interests in private health care providers, so there is a quite obvious interest for GPs to refer patients to institutions in which the same GPs have some kind of interest, which may well be financial. Not many will be able permananently to resist that kind of temptation.