Facing overwhelming opposition from the public and medical professionals, including the head of the British Medical Association Hamish Meldrum and the Chair of the Royal College of General Practitioners Clare Gerada, Secretary of State Andrew Lansley is pressing on with NHS reforms which a senior NHS manager said will cause a ‘bloody awful train crash’ in the short term and and many senior doctors believe will lead to the end of the NHS.
Public support for the NHS is at an all time high and appetite for an overhaul is at an all time low and yet Lansley, like the most bullish of orthopaedic surgeons, presses on regardless.
What does this mean for my patients and colleagues?
Put simply, Primary Care Trusts (PCTs) the 151 organisations that organise and plan the delivery of NHS services and control over 80% of the NHS budget will be scrapped over the next 3 years and replaced with GP consortia. The GP consortia will have to do what the PCT’s did. The main difference is that they will also have to make 4% year on year ‘efficiency savings’. Which is a political speak for cuts, in other words, less care and less staff. Lansley’s spin is that GP consortia will be better than PCTs because doctors are better at amputations than managers and will there for manage the cuts in a way that actually benefits their patients. This has never been tried before anywhere, ever. Nobody believes its possible to make savings of this degree without cutting services. Every GP practice will have to have a consortia representative, so that means when City and Hackney PCT combines with Tower Hamlets and Newham there will be roughly 200 representatives. GPs are notoriously difficult to organise (one reason why we’re not protesting) and on the whole they’re far more interested in looking after their practices than local politics, so most likely a handful will take on the representative role and then attempt to do what PCTs have struggled to do with experienced managers for years.
The other important thing to come out today is an analysis by the chief economist at the King’s Fund, Professor John Appleby, published on Health Policy Insight.
The Operating Framework has another surprise on tariffs: they are no longer to be fixed.
Trusts, including independent sector providers of NHS care will be free next year to offer their services at below the tariff price. Let me repeat that: there will now be competition on price.
This may help PCT budgets go further, but, as the Operating Framework notes rather blandly, ‘Commissioners will want to be sure that there is no detrimental impact on quality, choice or competition as a result …’.
I think this is the biggest shock. It means that there will be a race to the bottom, with providers competing to provide the cheapest possible services. Hospitals which have a complicated case-mix depend on cross-subsidising so that money raised from relatively straight-forward care such as outpatients, elective surgery or radiology ensures that the intensive care, A&E and rehabilitation units stay open. Lansley wants a free market in health services. What this means is that there will be a bun-fight to provide the profitable easy stuff and hospitals will be left to do the complicated, messy stuff. That means the old and vulnerable, the people with multiple chronic disease, people with dementia and other serious mental illnesses who cannot be looked after profitably will suffer the greatest deterioration in care.
It will be impossible for a consortia to pay hospitals above the ‘market rate’ even if they think its necessary to keep them from going bust because the government has set up Monitor to ensure competitiveness and stop price fixing.
It doesn’t have to be like this. The letter signed by over 250 senior doctors on Monday says,
Andrew Lansley’s aims of putting patients at the heart of care, involving clinicians in decisions about the provision of services and reducing managerial costs could be achieved without the massive structural upheavals of abolishing PCTs and SHAs. PCT Boards could be restructured, to give much better representation of clinicians,. members of the public and accountable members of Local Government. The present, costly healthcare ‘market’ could be abolished, saving billions in transaction costs and achieving the £20 billion ‘efficiency savings’ demanded by Sir David Nicholson.
So why is Lansley pushing ahead with reforms we cannot afford and do not want?
Because commercial health companies have been lobbying and advising the Department of Health (and Andrew Lansley) for the last 30 years in order to get their hands on the £100bn+ NHS budget. A free market in health care provision will ramp up demand, drive down quality, deprive staff of rights and force salaries down to the lowest level the market can sustain. It will create a postcode lottery in quality and range of services. Hospitals and surgeries will be forced to close becasue of being bankrupt even when patients lives depend on them and people will be forced to take out insurance to cover the gaps in provision. Business minded GPs will sell their practices to the private sector and the NHS will become nothing more than a brand, three letters to be stuck on to the front of a private equity firms latest aquisition.
If you care about the NHS it’s time to follow the students and get on to the streets.
“Every shred of evidence suggests that price competition in healthcare makes things worse, not better” Zack Cooper. Health Service Journal
A Better NHS 
My local hospital is a Foundation Trust and in answer to a question I put at the Annual General Meeting this year the Chief Executive said that all departments make a surplus except Paediatrics and A&E. The CE said that those two departments provided a social benefit (and I guess there is some legal requirements too). I am happy that he, and the FT accept that some departments subsidise others.
The problem is that other departments make surpluses, and the white paper invites employees to “take over services”. Well employees will only want to take over the services that make a surplus, right? So what will happen to those that make a deficit?
I predict that the FT will not have a children’s ward in 5 years time. It won’t be able to afford to.