Read NHS for Sale: Myths, Lies & Deception Online
Authors: Jacky Davis,John Lister,David Wrigley
There are many reasons why patient fees and up front charges are a bad idea. They discourage those who most need the system from using it, meaning delayed presentation and possible worse outcomes. Fees are expensive to means test and collect.
In the US chasing fees costs a fifth of total turnover. In Germany a proposal to collect a fee for GP appointments was abandoned when it was discovered that not only was the cost of means testing and then collecting it prohibitive but that patients on low wages didn’t attend their GP as soon as they should have done, and were more likely eventually to need emergency and/or more complex treatment.
See: Kahn JG, Kronick R, Kreger M, Gans DN, ‘The cost of health insurance administration in California: estimates for insurers, physicians, and hospitals’ in
Health Affairs
(Millwood) 2005;24:1629-39.
Fees for treatment fundamentally alter the doctor-patient relationship – threatening to destroy the trust between doctor and patient – and when patients pay up front they may expect to be treated as customers and sold what they want. Up front charges breach one of the founding principles of the NHS, that care is free at the point of need. Once the principle is breached further charges and top up insurance will follow (it is doubtful whether even Lord Warner believed that his NHS membership fee would remain at £10 per month for very long).
The introduction of fees is a zombie idea – a policy which refuses to die despite being killed by evidence – which is kept alive by right-wing politicians and think tanks. They don’t really believe that fees will rescue NHS finances but they do believe that if they can break the principle of free (at the point of need) and equitable NHS treatment then the door to top-up insurance, co-payments and the whole apparatus of a full market in healthcare will open up to them. For these reasons most doctors are vigorously opposed to user charges and upfront fees and maverick motions proposing fees are thrown out at every medical conference.
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What was noteworthy in the ponderous reports on how to rescue NHS finances was what they didn’t mention – the dog that didn’t bark in the night. None of them, including Simon Steven’s recent review, bothered to address one of the biggest wastages of the English NHS budget, the NHS market.
Since Thatcher introduced an NHS market – the so-called purchaser/provider split – NHS administration costs have escalated. Successive governments have been coy about what they amount to but the generally accepted figures are
that pre-market they were 6 per cent, then rose to 12 per cent under Thatcher’s internal market, and are now in the region of 15 per cent (in the US the administration costs involved in running health care as a market are estimated to be nudging on 30 per cent). Even by conservative estimates getting rid of the market would save between £5bn and £10bn a year for the English NHS.
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The NHS market has done nothing to improve patient care and indeed in 2010 the Commons’ Health Select Committee declared it to be a costly failure.
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Tendering, billing, accounting, chasing fees, legal costs all use up the precious NHS budget and divert money away from frontline care, and these costs have only been exacerbated by the Health and Social Care Act. For instance in 2012 the Audit Commission warned that classifying patients for accounting purposes was wasting valuable NHS time and money which would be better spent on the patients themselves.
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In 2013 the deputy chair of Monitor complained that the new competition arrangements were ‘a bonanza for lawyers and [management] consultants’ and could lead to scandals. He made his remarks ahead of a proposed
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merger of two hospitals which was supported by local doctors but opposed by an unidentified local private hospital. The merger, called for by the NHS hospitals themselves ‘to ensure the sustainability of services’, was eventually blocked by the Competition Commission on the grounds that it would reduce ‘patient choice’.
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David Lock QC, an expert in NHS contract issues, told the BMJ: ‘This shows the conflict between running the NHS as a public service and running it as a regulated market.’
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The lengthy battle over the merger is estimated to have cost the NHS (and thus the taxpayer) almost £2m in consultancy and legal fees.
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Competition, prioritised over co-operation in a
market-driven NHS, has not been shown to improve patient care. Even the then CEO of NHS England, David Nicholson, complained that the new laws promoting competition were hampering efforts to improve services, citing the blocked merger of the two trusts, and examples of GP practices not being allowed to federate.
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But, despite the lack of evidence, Lansley placed competition at the heart of the Health and Social Care Act and section 75, the HSCA regulations on competition, represented yet another Lansley lie. He had originally promised GPs that ‘it was absolutely not the case’ that Clinical Commissioning Groups (CCGs) would have to put services out to tender, and Earl Howe had promised those concerned about the regulations that there would be ‘no legal obligation to create new markets’. But the legislation showed them to be liars yet again.
After the passage of the infamous section 75 legislation Professor Martin McKee, in an article in the
BMJ,
lamented that the NHS was now at the mercy of lawyers, including some of the peers who had supported the Act
The future of healthcare in England lies in the hands not of politicians and professionals but of competition lawyers. Clinical commissioning groups … will think twice before invoking the wrath of one of the large corporations now moving into healthcare. With legal and contracting teams many times larger than those available to the commissioners, it is they who will be the ultimate arbiters of the shape of healthcare.
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There have already been expensive challenges from the private sector over the awarding of contracts and anecdotal reports of CCGs allowing contracts to remain with private
firms
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because of the fear of the legal costs of not doing so.
Despite the expense and the perverse consequences there seems to be no political will to abandon the English NHS market and use the billions that would be freed up for patient care instead.
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But of course having an NHS market in place is necessary to enable the privatisation of the English NHS, another policy which is wasting money hand over fist with no benefit for patients (see
Chapter 8
).
There are other ways of improving the NHS finances. PFI projects are crippling many hospitals and the debate is now raging about how to reclaim hospitals and the eye watering PFI repayments (which put Wonga in the shade) from the hands of the rapacious private sector. Significant amounts of money are being wasted on agency staff. Trusts were panicked and sacked permanent staff to save money – but then were forced to fill the gaps with agency staff after the Francis report called for safe staffing levels. The Nuffield Trust estimated that foundation trust spending on agency staff had risen by 27 per cent (£300m) in 2013-14, wiping out any savings from the sackings.
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Unfortunately short term thinking and the exigencies of the Health and Social Care Act – demanding competition at the expense of collaboration – mean that many ways of saving money are for the moment out of bounds.
There is of course a wider debate to be had when it comes to NHS funding. Would patients rather have Trident or treatment (unfortunately the government is not offering that particular patient choice)? Why not a hypothecated tax
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or Robin Hood tax for the NHS, or just make sure that corporate taxes are paid – dealing with tax avoidance (£25bn a year) and
tax evasion (£70bn a year) would produce more than enough money to bail out the NHS and put it on a stable footing. The politicians have answers to their manufactured and avoidable NHS funding crisis but are not prepared to use them.
The current crisis in the English NHS is largely down to repeated politically imposed ‘re-disorganisations’ and to arbitrary financial pressures. Failed political initiatives are followed not by insight or apologies but calls for yet more change because previous changes didn’t work. Against this background of government incompetence politicians and establishment NHS watchers complain that the NHS is unsustainable and unaffordable but the NHS market in England – a very costly failure – is still in place for what can only be ideological reasons. No major political party shows any inclination to fully remove the market despite all the evidence against it. No major health think tank seems able to grasp the nettle and recommend that it is abolished.
Expensive PFI projects, forced on trusts as ‘the only game in town’, are now causing trusts to fail – triggering cuts in other local hospitals and services. Privatisation has resulted in more money being wasted – staff time and resources are being squandered through compulsory tendering, and the NHS budget is going to shareholders and tax havens instead of frontline care. Enforced competition means NHS institutions can no longer collaborate to help patients. Staff have seen real earnings fall and work under the constant threat of their services being outsourced, cut or closed. Insecurity, criticism and fear do not produce a work place that is conducive to good patient care, but this is what staff face every day.
The English NHS isn’t perfect and campaigners have never
pretended otherwise, but in order to improve and remain patient-centred it needs stability and adequate funding and it has neither at the moment. The miracle is that despite political incompetence and meddling NHS staff still manage to deliver a good service to patients in what looks increasingly like a war zone.
The NHS has proved itself over the years to be a good model for delivering health care. It is cost effective, equitable and after appropriate investment was achieving good outcomes for patients with whom it is extremely popular. For 65 years it has allowed us to live free of the fear of the financial consequences of illness. Repeated assertions that it is unsustainable and unaffordable have no foundation, and should be challenged whenever they appear. And those who maintain that we cannot afford the NHS must be made to answer the most important question – if we can’t afford the most cost-effective health service in the world what can we afford?
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http://www.theguardian.com/society/2012/mar/13/nhs-collapse-without-reforms-lansley
.
Cameron said that greater competition within the NHS was the key to enhanced patient choice.
The Daily Telegraph,
20 August 2009
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The Health and Social Care Act 2012 requires commissioners to ensure good practice and to promote and protect patient choice.
NHS England document ‘Choice and Competition’
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Patient choice is integral to patient dignity and respect and lies at the heart of the doctor-patient relationship. It is very difficult to argue against. Politicians have exploited that fact to produce their own version of patient choice, which serves their ideological direction for the NHS rather than the patient. They have maintained that choice requires an increased number of providers of NHS care, which has in turn been the reason for opening the NHS up to the private sector, creating an NHS market in England.
The Health and Social Care Act has facilitated competition and marketisation of the NHS, always in the name of patient choice. But patients and their doctors have less choice now than they did when the NHS was first founded. The choices that most patients want – a good local hospital, a familiar GP who has the ability to refer them for specialist care when necessary – are increasingly under threat because of
Lansley’s ‘reforms’. CCGs are bound by contracts, referral management centres may deny the choices that doctors and their patients make and the awarding of profitable work to the private sector threatens to undermine local NHS services which the private sector can’t and won’t provide.
True patient choice does not require the NHS to compete with the private sector nor does it need a full blown NHS market. Indeed as the private sector takes over the delivery of more NHS care it is they who will pick and choose which patients they will take on. Patient choice is important but only when it is meaningful to patients, not when it is a means of facilitating a political agenda.
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Before the NHS was founded in 1948, choice for patients was limited. Individuals were able to choose their GP, dentist and optician, but choice did not extend any further. Many had no choice at all, denied access to health care by their poverty. With the advent of the NHS previously unaffordable services became available to everyone, and people rushed to sign up, forcing many initially reluctant GPs to join the NHS that they and the BMA had originally opposed.
GPs, even those who had been most sceptical about the new NHS, were able to refer any of their patients for any treatment they required, and to prescribe drugs in the knowledge that price would no longer prevent poorer patients receiving them. Hospital doctors were enabled for the first time to link up at local level with colleagues in what had previously been other small, rival hospitals, to share knowledge, collaborate in the development of new services, and treat a much wider cross-section of people.
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As a result, from 1948 until 1991 (which saw the creation of the NHS internal market) patient choice was a reality, a genuine entity, and included the possibility that health authorities could purchase care in the private sector if they so wished.
While the patient choice on offer during that period may have been sufficient for health professionals and their patients it was not the sort of choice that served the purposes of right-wing politicians and the private sector. Above all it did not allow private companies to get a foot in the door of the NHS and their hands on its guaranteed budget. That required the creation of a market. Markets mean competition and competition requires an increased number of providers alongside the NHS. Who better to step in and fill the gap than the private sector? The competition thus created would
result in better outcomes for patients by driving up standards and would give patients the holy grail of health care, more ‘patient choice’. Or so the argument went.