The good news first. The NHS was founded in 1948 on the principle that all treatment should be free at the point of use regardless of income. 63 years after its foundation the principle is largely intact. We have prescription charges and fees for dentistry and the work of opticians, although even these charges for the poor, old age pensioners and children are either considerably mitigated or waived completely. For the vast majority of illnesses and injuries NHS treatment is available and no one who is entitled to it need fear that they will be bankrupted by the cost of the treatment and care, and for the vast majority of ailments it is unlikely that the NHS will say no to treatment because it is too expensive. There are increasing disputes over the funding of expensive treatment, especially cancer drugs, but these affect only a tiny minority of patients and often a refusal to fund treatment stems from doubts over a drug’s efficacy rather than its cost. The sole major NHS blot is dentistry where it is difficult to find dentists to take NHS patients in many parts of the country.
Now for the bad news: the NHS ethos is under severe attack, not by piecemeal reform but frontal assault. The Coalition Government proposes to put 80% of the NHS budget into the hands of GPs and allow private health companies, many of them foreign, to enter the NHS market by bidding for contracts to run groups of GPs. They also intend to increase the outsourcing of non-GP NHS work to private companies. The clear intention is to destroy the NHS as we know it by making it predominantly a profit- driven service rather than one propelled by patient need. It is the penultimate act of a drama which has been playing out for 20 years. If these changes are pushed through the final act is likely to be outright privatisation.
The drama began in 1990 when the introduction of the “internal market” through the NHS and Community Care Act was the first major thrust at the unified integrity of the NHS with health authorities (HAs) given their own budgets to buy care for local populations hospitals and GP fundholders to obtain faster hospital treatment for their patients than non-fundholders . This not only caused a large increase in NHS administrators, but also struck at the universality of the NHS by allowing HAs to make different judgements about treatments and patients to be at the mercy of whether or not their GP was a fundholder or not.
Labour supposedly scrapped the internal market when it came to power in 1997, but this was more PR than reality because foundation trusts were established which led to hospitals once again competing for business. Blair also left in place the purchaser-provider split between primary care organisations and hospitals by scrapping GP Fundholding but replacing it with Primary Care Trusts (PCTs) through which 80% of NHS funding is now channelled. (think of PCTs as local area health managers funding GPs, dentists etc.)
The next breach in the integrity of the NHS was devolution (1999) which allowed Scotland, Wales and (eventually) Northern Ireland to manage their own health budgets. This caused substantial differences in funding between the four Home Countries, for example, prescription charges have been abolished in Wales and Northern Ireland but not in England and Scotland, and the variations in treatment, especially in the provision of expensive drugs, which were already in evidence before devolution were magnified.
The creation of The National Institute for Health and Clinical Excellence (NICE) in 1999 also complicated the issue of drug treatments after devolution. Amongst other duties, NICE investigates the efficacy of drugs and makes recommendations which NHS health providers do not have to abide by, but which are generally followed. After devolution Scotland had a separate version of NICE , which often makes different judgements about drugs from the original NICE, a body which covers only England and Wales. All this fragmentation of the NHS has resulted in some treatments being offered in Scotland and Wales but not in England, for example drugs such as Aricept, Reminyl and Exelon which are used to treat Alzheimer’s are being denied to early stage Alzheimer’s sufferers while it is available to such people in Scotland and Wales (Daily Telegraph 18 10 2006).
NHS change under the Blair Government was “continuous revolution” lines. In 2002 Strategic Health Authorities (SHAs) – which complicated the administration even more – were introduced followed by in 2006 by Patient Choice, which allowed patients a choice of several hospitals if they needed to go into hospital. This meant more administrative work, increased the competition between hospitals for patients and, because it was introduced only in England, a further diminution of the universality of the service.
To these strikes against the public service ethos of the NHS can be added the creeping privatisation of the NHS which ranges from the logistical and administrative to the medical. Hospitals have and are being built under PFI and their maintenance placed in private hands. Hospital meals and cleaning are provided by private contractors. (I was in a large London hospital in 2009 and it was chaos. There was a PFI contract for meals, a PFI contract for ward cleaning, a PFI contract for the multi-media installations (TV, internet etc). It was chaos because the ward sister had no authority over any of the contractors.) Medical supplies to hospitals are distributed by the German firm DHL. Most disturbingly, private medical firms, often American,have been granted massive contracts to take patients away from the NHS, a policy made all the more dangerous for the long-term security of the NHS because the treatments the private firms undertake are the simpler ones. The NHS are left with a reduced patient base for the simpler operations, which can result in the closure of NHS departments or even hospitals, and leaves the NHS with the more difficult and expensive cases to treat.
The present Coalition proposals are to abolish the PCTs and transfer the 80% of the NHS budget they administer to GPs. Apart from the question of practicality – doctors are trained to be doctors not businessmen and accountants – this will open the opportunity for private companies (especially American healthcare ones) who are profit-driven to take control of large sections of primary care provision. Even where that does not happen, GPs will be forced to work to a budget which means they will have to start routinely thinking not of the clinical needs of patients but the cost of treatment. Not only that, but patients will know that it is the GP saying yes or no to treatment not some anonymous person at a local area health office as is currently the case. This will utterly alter the relationship between patients and doctor.
What do we need to do to save the NHS? Apart from making private medicine pay its way, the NHS ideally needs to (1) not only stop further privatisation but to take back into its direct control that which has already been lost; (2) ensure that enough medical staff of all sorts are trained in this country and NHS posts reserved for them; (3) end the practice of money following patients; (4) fund NHS healthcare on the basis of an area’s population and demographic distribution; (5) retain and where necessary build new local hospitals; (6) restrict treatment to the hospital within a health authority area; (7) lay down a national schedule of treatments which must be offered throughout the NHS and (8) restrict NHS treatment other than emergency treatment to British citizens.
No 8 is necessary because a great part of the problem for the NHS in areas such as London is that it is being overwhelmed by the large number of foreigners who one way or the other either have a right to NHS treatment or who obtain it because NHS staff are unwilling to check whether someone is entitled to NHS treatment. Of course, there are supposedly reciprocal arrangements for Britons to obtain health treatment abroad but the balance of advantage is all against Britain because the range and quality of provision in many of the countries which provide supposedly reciprocal treatment is inferior to that of the NHS. There are also potentially vastly more foreigners eligible for NHS treatment than Britons eligible for treatment abroad, for example, 400 million non-British EU state citizens.
The NHS consultants would doubtless froth and whine about reduced private work opportunities and it might be necessary to give their NHS pay a very large boost. But there are not that many of them and the cost would not be vast in the context of total NHS spending.
That is the ideal. How much of it could be achieved as things stand is debatable because our EU membership and other treaties severely restrict control over both our borders and what any British government may do. For example, while we remain in the EU we cannot stop any person legally resident in the EU from coming here (apart from special cases of crime or terrorism) and either working for the NHS or claiming NHS treatment. PFI contracts also presents a severe obstacle because of the cost of buying up the PFI contracts, many of which extend to 30 years or more. Nonetheless it can be done, viz:.
“The NHS body was due to pay £2m a year for the next two decades to the private firm that built West Park Hospital in Darlington, County Durham. But after reviewing the costs, Tees, Esk and Wear Valleys Mental Health Foundation Trust decided to take advantage of a break clause in the deal. It paid £18m upfront to get out of the PFI contract 23 years early, but it now owns the hospital outright and expects to save £14m over the course of the deal once maintenance and inflation is taken into account.” http://www.telegraph.co.uk/health/healthnews/8296685/Hospital-saves-14m-by-getting-out-of-PFI-deal.html
Let the NHS become anything other than what it is, a national health service free at the point of use and you will never get it back. It was created in the extraordinary circumstances of the immediate post-war national solidarity when both the electors and the politicians were determined that Lloyd George’s boast of creating “A land fit for heroes” should not be mocked twice.
The NHS goes to the heart of what should be public and what should be private. The prime distinction is between service and profit. Public provision is the provision of necessary services to everyone, which private provision never has nor can supply: private provision is simply the provision of services to those who can pay. This has been lost sight of by governments over the past 20 years.