Tuesday, 29 March 2011

The NHS - a worrying future

Aneurin Bevan opening Park Hospital Manchester 5th July 1948
Among many recommendations in the Beveridge Report 1942, was one that said, "A new national health service to be established". Six years later, through the driving force of the then Health Secretary, Aneurin Bevan, The National Health Service came into being on the 5th July 1948. It was based on three core principles that have guided the development of the NHS for over 60 years.
  • That it meet the needs of everyone
  • That it be free at the point of delivery
  • That it be based on clinical need, not ability to pay
On Thursday, 27th January 2011, the Government published the Health and Social Care Bill. I have held back on giving my thoughts on it, as I wanted to take time to read as many arguments, for and against the Bill that I could. The Bill itself is far from easy reading (it is available on the Government website), being 367 pages long with 288 clauses, and the jargon (whatever happened to plain English?) makes difficult reading for a layman such as myself.

David Cameron
On the day that the Bill was published, David Cameron wrote an article that was intended to dispel the 'myths' as he saw it, being promoted by opponents of the Bill. He began by saying,

"This month, we published the Health & Social Care Bill, which sets out our plans to modernise the NHS to help it deliver truly world-class care for people. Running right through it is a new deal: we want to give you - the professionals - much more freedom to care for patients in the way you decide is best. ... But in return for this freedom from central control, we want the system to answer much more strongly to patients. By empowering choice, opening up competition and introducing new ways local people can get involved in shaping services, we want to give people, not politicians, the power to shape and improve the NHS".

Doesn't sound bad does it? Freedom + Choice = better services? I couldn't help thinking of Bevan's speech in the House of Commons on the 30th April 1946, when he said,

Aneurin Bevan
"In the last two years, there has been such a clamour from sectional interests in the field of national health that we are in danger of forgetting why these proposals are brought forward at all. ... Many of those who have drawn up paper plans for the health services appear to have followed the dictates of abstract principles, and not the concrete requirements of the actual situation as it exists".

'Paper plans' are what is being conjured with today. The question being asked by an increasing number of people since the publication of the Bill is whether it is opening the door to the privatisation of the NHS. The Government of course would answer no to this question. I have little difficulty in believing that it is not the Governments intention to privatise the NHS, however, intention is not the issue for me here. It is the consequence of the changes that are being made that is the issue. It is not where we will be tomorrow, but where we will be in five years time. Nailing my colours to the mast, I fear that in the future we will not have health care that meets the need of everyone; that is free at the point of delivery, or that is based on clinical need not ability to pay.

Andrew Lansley
In spite of the rhetoric contained in 367 pages and 288 clauses, the focus is money, not need. Andrew O'Hagan, in an excellent essay in the London Review of Books says, "Lansley's proposals borrow the sound of freedom in order to usher them (GP's) into a financial prison". If only the Health Secretary could speak with the clarity and conviction of Bevan, we wouldn't have to put up with,

"To further incentivize improved outcomes and financial performance, consortia will receive a 'quality premium' based on the outcomes achieved for patients and their financial performance. Some of the outcomes from the Commissioning Outcomes Framework will inform the premium - but not necessarily all, since some may not be suitable for translation into financial incentives". - Andrew Lansley

The Government want patients to have more choice and control over their care. This is in line with the mantra, "No decision about me, without me". This is a sound bite, but does it have real meaning? According to Dr John Lister, "The Bill gives the illusion of choice or power". In his view, ultimately, the only patient choice will be pay, or go without. (I'll mention Dr Lister again at the end).

Perhaps the biggest area of concern surrounds who holds the purse strings, and on what this money will be spent. Currently, Primary Care Trusts (PCT) control about 80% of the NHS budget (Around £80 million). All 150 odd of these will be phased out by 2013, and the money will be controlled by GP Consortia up and down the country. Each consortia will be encouraged to secure services from private hospitals as well as their local NHS hospital.

I think it best to let the medical profession speak about their concerns, as it is far more powerful than anything that I could say. It's also important to note that renewal, is, and always has taken place within the NHS, which could be replicated by others.

Kentish Town Health Centre
I've previously mentioned the excellent essay by Andrew O'Hagan on the changes planned through the Health & Social Care Bill. He says that he began to wonder what Britain now would seem like to LLoyd George and Churchill, Beveridge and Bevan who were visionaries of the welfare state. It occurred to him that when some of them sat down to dream about an ideal future, the things that floated into their minds must have looked a great deal like the present health centre in Kentish Town, London. He describes his visit.

"When you walk in, you wonder if you've somehow wandered into a North London satellite of Tate Modern. Unlike most receptions, Reception here appears eager to offer you a decent reception, and the building is full of colour, light, optimism and efficiency. People smile. It's a palace, actually, or a modern church of the common man, and I fancy that half the ailments in existence might be alleviated or cured just by sitting here waiting your turn. The NHS is, and will always be, an idea. It is an idea that requires constant renewal in the face of depreciation, and some of that renewal has clearly happened here. Beside a meeting area is a bank of fold-up bikes for the GP's to use on home visits. Upstairs there is a room where acupuncture can be administered to three patients at a time. There is a gym, a library, several patios with chairs, and soon they hope, a cafe. I'm thinking of moving in".

Kentish Town Health Centre
The centre is the brainchild of Dr Roy Macgregor, who spent over a dozen years bringing the dream to reality. Andrew O'Hagan was there to interview him, and his comments cannot be bettered. On the need for reform, he says,

"My biggest puzzle about these reforms is I don't understand why we're doing them. The GP community hasn't been balloted, they haven't been asked, they haven't been consulted. They've been landed with this role of suddenly holding the purse strings. I have dreaded the day when a patient walks into my room and there's a pound sign in front of them. And if someone comes to see me, in the new world, and they need an endoscopy to see if they've got a gastric ulcer or cancer, instead of meeting that patient's need immediately, I'll be thinking, hold on, in this practice we've sent 22 people this month for endoscopies, so I will think twice. I will think twice about giving this man what he needs and that will affect my clinical care. If I fail to send him for an endoscopy and that man gets cancer, I will have been guilty of giving that man bad care".

Dr Macgregor was asked about Andrew Lansley's statement that GP's are best placed to make judgements about how to distribute scarce resources, because they can assess the need. His answer,

"The need, yes. But not the cost of the need. If they care about our assessment, why are they getting rid of 150 Primary Care Trusts? Because that is how our 'in the room' experience was fed through. So now we'll have, aha, 150 commissioning groups to replace the 150 PCT's abolished. The new groups will have GP's obligatorily involved in costing, but the whole thing is just a route to something much bigger and more damaging".

To O'Hagan the question was 'What?' The answer from Dr Macgregor was, "Oh, the dismantling of the NHS. This Lansley plan is the first step to privatising part of the NHS and forcing people to have 'top-up' private insurance". Later he says, "This Government's commissioning proposals are blind and unthinking. They will destroy, at one fell swoop, the doctor-patient relationship, which has been the most important element in general practice over the last 60 years. It will destroy the confidence you must have that when people come to see me with a problem I will do what is in your best interest. People who don't have insurance, and who generally won't make a fuss, i.e. the poor, will suffer immediately from what can only turn out to be a messy and socially divisive set of changes". A health system that once acted against inequality is now set to enshrine it.

Let me end by recommending you listen to a video on the Health Emergency Organisation website. Click on the link http://www.healthemergency.org.uk/ and then start the video. It's a talk lasting about 26 minutes by Dr John Lister, who blows away the slick marketing of the Government plans, and shows that their real intent is to fragment and privatise the health service. If you read or see nothing else, make sure you view this video.

So, in the not too distant future, I believe that receiving health care will be dependent on our ability to pay (whether through savings, insurance or whatever). Those with no savings, or who cannot afford insurance, will once again in life be dependent on charity. Will this mean a return to charity hospitals for the poor? Don't mock, for who knows what the future may hold. If my final paragraph scenario turns out to be true, then it is indeed a frightening prospect. I'm glad to be in the company of Bevan, who said,

"I believe it is repugnant to a civilised community for hospitals to have to rely upon private charity". I still hope that sanity will eventually prevail, and that aspects of the Bill will be changed. However, I have often been guilty of travelling more in hope than expectation.

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