The Lib dems and the NHS, by Clive Peedell and Shirley Willams

Two articles about the Lib Dems and the NHS. The first by Shirley Williams, Liberal Democrat Peer, Published in the Times on 28.2.2011 and the second by Clive Peedell, co-chair of the NHS Consultant’s association published in Hospital Doctor Blogs.

I can’t support the coalition plan for the NHS
by Liberal Democrat Peer, Baroness Williams of Crosby

Some of the health service reforms are valuable but the scale is too great and too many questions are unanswered.

Being in a coalition government produces difficult dilemmas. I support the coalition agreement. I believe the coalition is necessary to tackle our immense financial crisis. But every now and then, a dilemma emerges that cannot easily be resolved. Such a dilemma for me is Andrew Lansley’s health policy.

I campaigned nationwide in the last general election on the basis of the Liberal Democrat manifesto, reiterating our strong commitment to the National Health Service. The coalition agreement, which promised “to stop top-down reorganisations of the NHS” and made no mention of insisting on competition, posed no problems. On reading it I felt the NHS was safe in David Cameron’s hands.

But a recent report by the candid and incisive Commons Health Select Committee pointed out big differences between the agreement and the subsequent White Paper, Equity and Excellence: Liberating the NHS: “The coalition programme anticipated an evolution of existing institutions, the White Paper announced significant institutional upheaval.”

As a Liberal Democrat parliamentarian, I am under no obligation to support policies outside the agreement. Indeed, I have a moral duty to the voters I asked to support us to find out exactly what Mr Lansley intends and its implications for the NHS. So I have a few questions.

But first let me say what is valuable in his proposals: the recognition that the NHS must become more efficient if an ageing population is to have good care; the joining-up of healthcare and social care vital to the wellbeing of sadly neglected elderly people; reducing bureaucracy, though it will be easier said than done; ending Labour’s often niggling interventions in professional judgments, which left a legacy of resentment. There is, however, an unresolved tension between an emphasis on good management for obtaining efficiency savings, and the plans for radically reducing NHS staff.

I have four questions: the cost of the reorganisation, the accountability of the new GP consortiums, the role of the private sector and patient choice.

The cost
What is the cost? The Government must reduce public spending from 2011- 2015 by £80 billion. If it can’t, its strategy will have failed. The NHS accounts for a third of England’s revenue budget and 11 per cent of its capital budget. It faces relentlessly growing demand.

David Nicholson, the chief executive of the NHS and now of the National Commissioning Board, noted in 2009 that the NHS must find £15-£20 billion in efficiency savings in the next four years. But he himself believes that “to do so will require clear and effective management every step of the way”.
Key to this is a 40 per cent cut in management costs. Already hundreds of managers have left Primary Care Trusts at a cost of about £1 billion. The impact of this is not yet known, but GP commissioning consortiums are bound to look for good managers, some of whom will be hired from outside the NHS. They are likely to cost more. Some 20 per cent of the savings will come from moving patients from specialised hospital care to treatment by GPs or nurses in the community.

The final 40 per cent will have to come from clinicians and hospitals, an estimated £2 billion a year. Such huge savings will almost certainly entail an element of rationing. Waiting lists for routine operations are lengthening, and in some cases they are being postponed or cancelled. As the National Audit Office observed: “Government reorganisations … frequently entail higher costs than anticipated”.

Accountability
What arrangements are there to hold GP consortiums accountable for quality of care? Primary care trusts (PCTs) were accountable to Strategic Health Authorities and, ultimately, to the Secretary of State. They were overseen by local authority committees. Meetings were held in public and the minutes made available. The new consortiums, responsible for about £80 billion, are not obliged to meet in public. Local health-watch groups may scrutinise them but have no power to hold them accountable. Suggestions for adding knowledgeable lay people, members of other medical professions such as clinicians or nurses and elected local representatives have come from many quarters, but it will be up to each consortium to decide for itself.

Accountability upwards will be to the Secretary of State via the NHS Commissioning Board, but the board has no powers of oversight.

The private sector
What are the Government’s intentions here? Private medical practices work closely with NHS colleagues and were encouraged by Labour to bid for contracts at a price determined by the NHS tariff. Competition for these contracts depended on the quality and effectiveness of service. There is a cap on the proportion of private beds in Foundation Trust hospitals, which varies according to earnings from private patients and is much higher in London. Last year the private sector treated 220,000 patients.

The Government is now preparing to remove the cap, renegotiate the tariff and require the National Commissioning Board to promote competition. This will open the door to competition on price, not just quality. Many clinicians fear that the private sector will skim off profitable routine operations, leaving expensive, complicated treatment to the NHS.

The body that will license health providers is Monitor, which oversees foundation trusts. Its chairman, David Bennett, wants healthcare exposed to competition like gas and rail. British Gas raised energy prices by 7 per cent last year, while making £700 million in profits. Since rail privatisation, the UK had paid the highest fares in Europe. Should this inspire confidence?

Patient choice
How does the Secretary of State reconcile this with the need for large savings? Mr Lansley puts great emphasis on the involvement of patients in their own treatment. That’s good but achieving it in practice is hard. Articulate and self-confident people are likely to benefit, but elderly or busy patients will have little basis for their choices beyond rumour or GPs’ advice. Choice must be balanced against the realities of a publicly funded service.

Underlying the debate about health is another about values. For some of us, health care is a public service, strengthened by partnership and co-operation, the model in most Western European countries. For others, it is a market in which price determines quality, the US pattern. A June 2010 study of 11 health systems by the US-based Commonwealth Fund said of the US system: “Compared with … Australia, Canada, Germany, the Netherlands and the UK, the US system ranks last or next to last on five dimensions … quality, access, efficiency, equity and healthy lives.” The NHS was the second least expensive per person after New Zealand, and came first on effective care, efficiency and cost-related access, and second on equity and in the overall ranking. Why we should dismember this remarkably successful public service for an untried and disruptive reorganisation amazes me. I remain unconvinced.

Traditionally, the Liberal Democrats have always stood on a political platform promoting a more just and progressive society, based on a mixed economy, supporting public institutions to ensure equal opportunities for all.

They have a proud heritage in assuming responsibility for the social security and health of the nation’s citizens, which includes David Lloyd George’s introduction of a welfare system between 1908-14. This was followed by the Beveridge report in 1942, which led to the creation of the Welfare state and set the foundations for the formation of the NHS by the Labour Party.

Not surprisingly they have a long history of visceral dislike of the Conservative Party.

However, in 2001, the Lib Dems policy review, chaired by Chris Huhne, forged the party’s first steps towards the erosion of public monopoly in public service provision. This change in policy direction was rubber stamped by a defining moment in the history of the Liberal Party with the publication of the Orange Book in 2004, with contributors including the current cabinet ministers Nick Clegg, Vince Cable, and Chris Huhne.

This signalled a major change in direction of policy towards the right, with a focus on free market economics and the use markets as a solution to social and societal problems. Notoriously, the Orange Book called for a social insurance scheme with private providers to replace the NHS. It was therefore no surprise that the 2010 Liberal Democrat manifesto suggested market reform of the NHS, including abolition of SHAs, a direction of travel now emulated by the coalition government’s Health and Social Care Bill.

It should therefore be of no surprise that the leadership of the Liberal Democrats are supporting the Bill, which aims to dismantle the NHS and betrays their Party’s underlying principles to protect public services. However, many backbench Liberal Democrat MPs and grassroots Liberal Democrat members do not subscribe to the Orange Book camp’s view and they must surely be extremely concerned about the direction of travel that Nick Clegg has taken them. In fact, there is a significant section of Liberal Democrat MPs who belong to the centre left Beveridge Group, which was formed to counter the right leaning Orange Book liberals.

One member of this group, Andrew Carmichael, MP, stated that: “Should the party of Beveridge and Keynes approach issues with a prejudice in favour of the free market system? Should we enter every policy debate with an underlying belief that private is always better than public? I certainly do not think so.”

These MPs could therefore hold the key to preventing the demise of the NHS as a publicly funded and provided service. The whips will be making sure that they vote in favour of the Bill and this was successfully achieved with the second reading of the Bill. I would therefore like to make a plea that they start to listen to the concerns of the medical profession and move away from the market-based policies that are designed to cause the ‘creative destruction’ of the NHS. This will end up destroying their own party and they will have no excuses.

I would also ask that doctors that live in the constituencies of Liberal Democrat MPs, write to them or meet them in their surgeries to discuss the damaging consequences of the Health and Social Care Bill.

If the Bill passes, then the Liberal Democrats must be made to shoulder the blame for the demise of the NHS. This must include the Beveridge Group, who have been so weak as to allow their own party to become hijacked by politicians who share almost identical ideology to their Conservative masters.

The following list of Liberal Democrats belong to the Beveridge Group. You can contact them here.

Norman Baker MP

John Barrett MP

Annette Brooke MP

Alistair Carmichael MP

Tim Farron MP

Don Foster MP

Andrew George MP

Mike Hancock MP

John Hemming MP

Martin Horwood MP

Simon Hughes MP

Chris Huhne MP

Mark Hunter MP

John Leech MP

John Pugh MP

Dan Rogerson MP

Bob Russell MP

Adrian Sanders MP

Mark Williams MP

Roger Williams MP

Stephen Williams MP

Jenny Willott MP

Richard Younger-Ross former MP

Tags: Lib Dems