NHS for Sale: Myths, Lies & Deception (10 page)

True patient choice is further eroded by the threat posed to local services by the private sector. Elsewhere in the book evidence is provided to show how the privatisation of cherry-picked services can easily undermine the local NHS, which is left providing the expensive and emergency services that are of no interest to the private sector.

BBC’s
Newsnight
recently
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produced a short film extolling the private sector delivery of NHS elective surgery because some individuals interviewed rated the private care they received slightly more highly than NHS care. But if those same patients understood that their local NHS services were threatened by the local private sector contract they might take that into account when assessing the desirability of that contract. The price paid for the choice of an NHS hip replacement in a private hospital may look too high if the consequence is the destabilisation and possible loss of local NHS orthopaedic and trauma services. The private hospital will not be interested in that same patient when they fracture their hip or need complex orthopaedic treatment that the private firm is not contracted to deliver. The argument is far more complex than
Newsnight
suggested and patients and the public deserve a much better account of it from supposedly responsible media.

The tendering out of sexual health services also provides a classic example of how patients may end up with less choice, limited access and a worse service once the private sector takes over a contract. In 2013 representatives of the UK’s hospital doctors and sexual health specialists wrote to all local councils in England strongly advising them not to put services that provide contraception and diagnose sexually transmitted infections out to competitive tender.
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They claimed that outsourcing posed several ‘key threats’, including reduced
access to clinics and treatment and a reduction in the quality of patient care and added:

Tendering has negatively impacted on the provision of sexual health services, destabilising, disintegrating and fragmenting services, causing significant uncertainty amongst patients and staff, and reducing overall levels of patient care.
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The cost of imposing competition on the English NHS is high both in terms of the money wasted on running a market (upwards of £5bn a year), and in the deleterious affect it has on the service. Other chapters describe the perverse effects for patients of competition rather than collaboration, and the cost and disruption of the plethora of competition lawyers crawling over and profiting from the NHS market. Recently NHS England was forced to concede that there was a ‘paucity of evidence’ that choice and competition produced any benefit to patients.
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Their policy director admitted that ‘the direct evidence of where best competition and choice works to improve outcomes is fairly limited’ – a shocking admission about a policy which has been used to transform the English NHS into a market place and which has wasted untold amounts of NHS money at a time when the service is suffering severe financial pressures.

But, as Professor Calum Paton points out in his review for CHPI, it is perfectly possible to abolish the market and yet still provide patients with choice. GPs can refer patients to an NHS provider of choice, as they once used to. Paton concludes:

Just as markets may not involve choice, choice does not require markets except in the basic sense that plural provision exists. Choice existed from 1948 to 1991, after which the market restricted it. The challenge in the 1980s was to improve the resource allocation formula through regional strategy: then the mechanisms to reconcile choice with effective service reconfiguration would have existed. But this agenda seemed dull to the 1980s Thatcherites who wished to marketise the NHS for ideological reasons. And this dull but valuable truth has been lost over 25 years of exciting but damaging market hegemony.
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Since the 1980s, the concept of choice has been used not so much as a way to improve the patient experience but as a lever to replace the planning of services with competition, and a device to carve out a share of NHS budgets to bolster a private sector that has no chance of surviving without extensive government patronage. As Paton shows, competition, so destructive and expensive, was never necessary to provide choice, and indeed as the privatisation of the NHS proceeds choices available to patients will reduce. The private sector is not keen on competition, preferring large monopolies, and patient choice is already on its way to becoming yet another myth. The real choice that patients want – a good reliable local hospital, a familiar GP who knows you and listens – are under significant threat in the new marketised NHS. In future the real choice is likely to lie with those providing health care. They will choose fit, young and profitable patients and reject the elderly, the chronically sick and those with complex problems, as already happens in the US.

London GP Jonathon Tomlinson summed up choice thus on his excellent blog:

Patient choices are integral to dignity and respect and are at the heart of medical ethical principles and the doctor-patient relationship. This is why doctors are so sensitive to criticism that we do not care about patient choice. The reason so many of us who care for patients every day object so strongly to the way that patient choice is framed in the NHS reforms, is that patients and their choices are not being treated as ends in themselves, but merely as means to an end; they are to become subservient to the goals of market based competitive healthcare.
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Interestingly nothing to do with results (outcomes) of treatment in terms of the health of the patient, which is not taken into account; it is simply a fixed tariff of payments for each treatment, based on the average costs of NHS providers.

So let’s be clear – our aim is a major transfer of responsibility to the GP community; in order to empower clinical decision making and improve outcomes for patients.
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Andrew Lansley

You will have the freedom to work with whoever you want to in commissioning health services.
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Andrew Lansley

When Andrew Lansley presented the Health and Social Care Bill to a surprised audience he was emphatic that the intention was to hand power and money to GPs. Initially 80 per cent, (subsequently downgraded to 60 per cent) of the NHS budget was to pass to Clinical Commissioning Groups run by GPs who would make the right decisions for their patients, with minimum interference from central government.

The reality has proved to be quite different. Few GPs have the enthusiasm, time or expertise to take on the work involved and the number of GPs on CCGs has declined. Faced with diminishing resources and driven by central diktats CCGs have limited choices and hard decisions to make about how to save money and ration care. Contrary to firm government promises CCGs now have to tender out almost all services, wasting money and clinical time and resulting in an increasing number of contracts going to the private sector.

Some CCG work is already being undertaken by Commissioning Support Units, due to be outsourced in 2016. CCGs are likely to find they have little to do apart from rubber stamp their decisions and those coming down from NHS England, and take the blame for problems. The majority of GPs now believe that they have been set up to take the blame for rationing health care.

Some of the GPs remaining on CCGs have interests in the private health companies bidding for their CCG services, giving rise to conflicts of interest hitherto unknown in the NHS.

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At the heart of Lansley’s legislation were two attractive and important promises. One was that patients would be at the centre of the NHS, their choices paramount, a promise encapsulated in the repeated undertaking that there would be ‘no decision about you without you’. The other was that GPs would be given the majority of the NHS budget to buy care for patients as they and their patients saw fit. GPs knew best what patients needed and were to be given the power and the money to deliver it. Time and again GPs were told they would be ‘in the driving seat’, with control of the NHS budget, and that they would be calling the shots on behalf of their patients. These promises have turned out to be worthless, a deliberate deception of GPs and the public.

Lansley’s HSC Bill proposed radical structural changes to primary care, with the abolition of 150 Primary Care Trusts as local commissioners of services and the creation of a larger number of new bodies – Clinical Commissioning Groups (CCGs) – to take their place. It was clear from the outset that the proposed changes would have a significant impact on primary care and on the working life of all GPs.

Many opponents of the Bill questioned whether the majority of GPs had the interest, time or expertise to commission services on such a large scale and some also doubted that the government intended to keep their word about handing so much power to GPs. Both doubts were soon justified. GP commissioning turned out to be the bait in the bear trap, used to lure GP leaders who should have known better into accepting legislation which would be disastrous for primary care. As a result GPs have ended up with ‘less money, more complexity and all of the blame’.
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At the same time the HSC Act has opened up key sections of the NHS – including now the work of commissioning – to the
private sector, which is increasingly displacing GPs when it comes to making decisions about where and how to spend the NHS budget. Many of the new contracts being offered up for competitive tender focus on a new ‘lead provider’ which will ‘coordinate’ services and allocate resources.
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GPs are supposedly elected to their roles on Clinical Commissioning Groups by their locality GP peers for a period of three years, although many posts are uncontested: in 2011, as the shadow CCGs were formed, research by
Pulse
magazine found 95 per cent of board members had not faced any electoral process.
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Board members have a say in the policy and commissioning decisions of the CCG, but these GPs can often spend as little as one or two half days per week on CCG business. This leaves much of the real day-to-day work to be undertaken by managers (many re-employed after being made redundant as PCTs closed down) or by Commissioning Support Units, run by NHS England – units which will have to be put out to competitive tender and possible privatisation by 2016. Perhaps one or two GPs in a CCG, such as the clinical chair, will spend three or four days a week on CCG business.

A survey undertaken by
GP
magazine via a freedom of Information request
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found that GPs now make up less than half of CCG Board members. Of 2,720 Board members, just 1,188 are GPs. This leaves them in a minority if any votes are taken, so they can hardly be described as being ‘in control’.

The FoI request also showed a rapid increase in the number of GPs abandoning their role on CCGs. In one three month period in 2013, 51 GPs gave up their role whilst 68 quit in the
whole of 2012. There seems to be a general loss of interest as GPs realise how little influence they really have. CCGs have to follow the diktats from central government and try to make ends meet with budgets that are frozen in real terms whilst demand for health care increases, a far cry from the power and influence they were promised.

A report by the King’s Fund
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showed GPs had limited understanding of the governance arrangements of CCGs and of the constitution that governs them. There was significant disparity of views between those GPs involved in CCGs and those not involved. For example, 81 per cent of CCG leaders felt that decisions made by the CCG reflected their views and those of colleagues, compared with 38 per cent of those without a formal role on the CCG. Many respondents to the survey were highly sceptical of the notion of the CCG being owned by local GPs and saw the CCG as an administrative structure sitting above practices rather than something that is composed of and led by its member GPs.

Lansley argued that GPs had wanted more influence for years, and that handing them the budget would allow local control by the very doctors who knew their patients best. But he had also calculated that at a time of increasing financial constraints GP commissioning offered a perfect opportunity for politicians to blame any resulting problems on ‘local decision making’ and thus absolve themselves of responsibility.
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In June 2014 Kailash Chand wrote: ‘The NHS bashing, which is now an almost daily feature from politicians needs stopping. Hunt, instead of naming and shaming GPs,
please invest in training, education and funding in primary care.’
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Jeremy Hunt accused GP leaders of scaremongering when concerns were raised about general practice. Mention is made elsewhere of Hunt threatening to name and shame GPs for not referring patients for enough hospital tests while at the same time CCGs are encouraging them to keep patients away from hospitals in order to save money.
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