NHS for Sale: Myths, Lies & Deception (3 page)

Chapter 4
challenges the argument central to the recent reforms that general practitioners will be in the driving seat. In practice, many are walking away from the new commissioning
groups, disillusioned by the gap between what was promised and the reality, shocked by some of the more blatant conflicts of interest, and reluctant to accept blame for the inevitable rationing as budgets come under pressure.

Chapter 5
examines the argument that the reformed NHS will be cheaper and have less bureaucracy, showing the enormous costs of compulsory tendering, both for purchasers and providers.
Chapter 6
questions whether the reforms deliver on the promise to give more power to local people. As became clear in Lewisham, when local people objected to the downgrading of their local hospital they struggled to be heard and had to take the Secretary of State to court to ensure that he would listen.
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Chapter 7
discusses the increasing secrecy of decision making in the NHS, as millions of pounds are disbursed under contracts that are deemed ‘commercial in confidence’. It also explores the consequences of freeing the Secretary of State from the requirement to account to parliament for the operations of the NHS.

Chapter 8
tests the claims made for the purported efficiency of the private sector and finds them wanting, while
Chapter 9
asks whether the NHS really is being privatised. Government ministers claim they are not, pointing to the still low share of total spending on private providers while ignoring the direction of travel and how, even in the most market-oriented system, the USA, the private sector only wants those parts from which it can make profits, leaving the public sector to pick up the rest.

The book concludes by looking to the future.
Chapter 10
considers commercial interests, cuts, closures and ‘reconfiguration’.
Chapter 11
peers behind the curtain to reveal things they don’t want us to know about the dense
network of conflicting interests promoting the market in health care.

For the first time this book brings together the evidence of how recent policies have undermined the NHS. It concludes with a challenge to us all. Crucial decisions will have to be made in the months ahead that will have profound consequences for the survival of the NHS. They include those that readers of this book will make in May 2015 as they cast their ballots, those that political parties will make as they write their manifestos, and those that health workers must make as they seek to preserve the health system that, despite its underfunding, remains among the best in the world.

I don’t know how much any of you realise that with the Lansley act we pretty much gave away control of the NHS, which means that the thing that most people talk about in terms of health [the NHS] … we have some important strategic mechanisms but we don’t really have day-to-day control.

Jane Ellison MP, Tory public health minister, June 2014

It’s hard to believe, but it was not so long ago that the Conservative Party was saying – ‘We’ll cut the deficit, not the NHS’. Cameron promised there would be no more ‘top-down reorganisation’ of the NHS and pledged to halt further closures of Accident & Emergency and maternity units. Before the election of 2010 Conservatives were touring the country challenging Labour’s record on the NHS, promising year by year increases in NHS spending in real terms.

All of those promises were worthless. The Tories – kept in office by servile Liberal Democrats – have cut public spending, but they have not, as promised, cut the deficit. Indeed even stiffer cutbacks to public sector budgets are required in the next parliament.
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They have effectively frozen NHS spending, with increases only microscopically higher than inflation, in the meanest five years for funding increases since the NHS was established in 1948.

This funding squeeze has also ensured that the ‘moratorium’ on closures of A&E and maternity units so proudly announced by Andrew Lansley in the summer of
2010 had become ancient history by the autumn of the same year. The
Daily Telegraph
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now calculates that some 66 A&E and maternity units have been closed or downgraded since 2010, or are still under threat.

To make matters worse Cameron’s government has forced through the biggest top-down reorganisation in the history of the NHS, with a piece of legislation longer and more complex than the 1946 Act that took hospitals into public ownership and established the NHS as a ground-breaking, integrated public service free to all at point of use, and funded from general taxation.

Health Secretary Andrew Lansley’s White Paper ‘Liberating the NHS’, published in July 2010, tore up both Tory and Lib Dem manifesto promises and set out plans for the wholesale top-down reorganisation of the NHS. It was followed swiftly by the Health and Social Care Bill, which eventually received the Royal Assent in 2012 and took effect from April 2013.

The Tories’ own verdict on the legislation shifted from uncritical support for Lansley’s massive and complex 400-page Bill, to uncertainty mixed with dogged determination to force it through during the brief ‘listening exercise’ in the spring and summer of 2011, which changed little of substance. By February 2012 David Cameron had to deny stubborn rumours that he and other leading Tories wanted Andrew Lansley ‘taken out and shot’ for his handling of the Bill.
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Section 75 of the Bill – later reinforced by powerful regulations implemented on the eve of the Act coming into force – set out far-reaching requirements for Clinical Commissioning Groups (CCGs) to put services out to competitive tender. The foundation trust regulator, Monitor, was given wide new powers to regulate the NHS as a whole and, in the amended Bill, to enforce both competition and integration of services.

The competition rules brought completely new players into the regime of competition in the NHS: the Competition Commission and the Office of Fair Trading, both since superseded by the Competition and Markets Authority, began ruling on mergers of trusts,
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and obstructing collaboration between trusts to improve patient care
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– on the grounds that it impeded competition.

EU competition law has also become a factor, with its insistence on a so-called ‘right to provide’ which allows companies to force the opening up of public services to competition. More recently the controversial Transatlantic Trade and Investment Partnership – being negotiated between the EU and the US administration, with full support from the British government, and leading members of the Parliamentary Labour Party – has also become a potential factor. It may create major obstacles to bringing privatised services back into public ownership and control.
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Labour’s opposition to Lansley’s Health and Social Care Bill was weak at first. The party mounted no significant campaign outside Parliament. The unions, following suit, were also slow to develop any real campaign. In bizarre fashion the most influential early opposition to Lansley’s Bill came from the Tories’ coalition partners, in particular from LibDem rank-and-file party members. At their spring conference in
2011 they were manoeuvred out of a vote that could have overturned Liberal Democrat support for the Bill.

The LibDem reservations were enough to force Cameron into a highly unorthodox ‘pause’ in the process of legislation in late spring and early summer of 2011. The tame former GP leader Professor Steve Field was brought in to head up an NHS Future Forum in a ‘listening exercise’ which managed to avoid listening to any significant numbers of the general public or campaigners. After the ‘pause’ it was back to business as usual. The huge and complex Bill, barely altered, ground on through the Commons, where it seems that among the many Tories who voted for it without understanding it was Jeremy Hunt, later to be named as Lansley’s successor as Health Secretary.
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One group who remained unconvinced from beginning to end were GPs – whose main voice challenging the Bill was not the docile, ambivalent BMA but the Royal College of General Practitioners. Each RCGP poll showed a large majority of those allegedly empowered by the Bill declaring their opposition to it. Early in 2012, recognising this huge credibility gap, Lansley issued a letter to all GPs, which appeared to reassure them that – contrary to all but ministers’ reading of the Bill – there would be no requirement on CCGs to privatise or put services out to tender (see
Chapter 4
). It was only at this stage that Labour – with Andy Burnham now leading the way as shadow health secretary – began to wage a belated, but largely inward-looking campaign against the Act. The TUC unions threw resources into a big, lively but again belated rally in Westminster Central Hall, in March 2012, but it was too little, too late.

The LibDem spring conference in 2012 saw the definitive collapse of any real opposition as another critical motion was blocked by party leaders, terrified that a breach in the coalition would trigger an early election. Shirley Williams, the party’s proclaimed standard-bearer, meekly accepted Tory assurances and threw in the towel, giving her support for the Bill, thus ensuring it passed the Lords on the strength of LibDem votes. LibDem votes also carried the controversial Regulations that gave real teeth to Section 75 of the Act. Among other things the Regulations set out the few, wholly exceptional circumstances in which CCGs might be excused from putting services out to tender.

The consequences of this wholesale reorganisation of the National Health Service via the Health and Social Care Act are already starting to make themselves felt. Organisational upheaval, the fragmentation of services and organisations due to new requirements for services to be put out to tender, and the underlying, worsening financial squeeze on the NHS (driven by the Cameron government’s commitment to austerity and cuts in public spending until at least 2021) are combining to push the system ever further into crisis.

There are indications that even the Tories themselves, having pushed the Act through, are now beginning to view this huge piece of complex legislation as a major mistake, with David Cameron reportedly admitting he did not know what it entailed, even when he took personal charge of getting it onto the statute book.
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Other Tories have been equally baffled or critical of the Act and its outcome. Tory public health minister Jane Ellison (as quoted above) was recorded in June 2014 telling a Tory Reform Group meeting
that as a result of the Act the government had effectively given away day-to-day control of the NHS.
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Clause 1 of the Act was the key factor in giving away control, abolishing as it did the duty of the Secretary of State to provide universal and comprehensive services in England.

Section 75 of the Act, backed up by wide-ranging additional regulations, focuses on creating a competitive market in health services, and increasingly the contracts offered up are being won by the private sector.
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Vital cash from NHS budgets is flowing out of the NHS into private companies seeking profits from health care. While the private sector revels in its rising revenues, the money they win in contracts is taken from the limited NHS budget, leaving less for the NHS trusts and services which remain the bedrock and only option for many key services which the private sector sees as risky or unprofitable.

Emergency services and care of the most seriously ill suffer cuts, while managers have to focus their attention on tenders offering the easiest elective and community services to profit-hungry companies seeking to slice out the safest returns. NHS management time and resources which should be concentrated on patient care are increasingly being squandered on complex contractual arrangements and ‘commercial’ activity,
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supervised by the regulator Monitor (with its additional powers to enforce competition) and even by the newly-formed Competition and Markets Authority.

What has all this done to our NHS? One of the first casualties has been the accountability of the service. The Commons Public Administration Select Committee has raised searching questions over the level of accountability, if any, of the
new, all-powerful national commissioning board, known as NHS England, which controls some £95.6bn of NHS funds. Asked what the system of accountability was between the Department of Health and NHS England, the civil servant responsible gave the committee a bafflingly convoluted 300-word answer. At the end of 2014, Bernard Jenkin, Tory chair of the Committee questioned the complex relationship that the Act has established between the Department of Health and NHS England, the ‘arm’s length’ commissioning board.
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