NHS for Sale: Myths, Lies & Deception (2 page)

In fairness, this reflects the weaknesses of the British system of government, where there are few if any checks
on the executive. As long as a prime minister can ensure a majority in parliament (which is rarely difficult given systems of patronage and the dark arts of the whip’s office) he or she can ensure the passage of any legislation, no matter how flawed it is. Some legislation has perplexed those charged with implementing it; for example, Lord Justice Rose described the Criminal Justice Act of 2003 Act as ‘at best, obscure and, at worst, impenetrable’
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and in a subsequent case, when faced with the same Act, concluded that

The most inviting course for this Court to follow would be for its members, having shaken their heads in despair to hold up their hands and say “the Holy Grail of rational interpretation is impossible to find”. But it is not for us to desert our judicial duty, however lamentably others have legislated.
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As Anthony King and Ivor Crewe note, in their book
The Blunders of our Governments,
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there are many other examples of how successive British governments can introduce policies that make things worse, often at great expense. These include Individual Learning Accounts, which despite numerous warnings were an open invitation to organised criminals to extract money from the government, numerous failed information technology (IT) schemes, which had many of the same features, although that time with the IT companies extracting the money. They identify several factors. One is the almost complete disconnect between ministers and civil servants on the one hand and the general public on the other. Another is a form of groupthink, whereby dissenting opinions are either suppressed or ignored. This happens at all legislative stages. Nigel Lawson is said to have missed a
crucial meeting on the Poll Tax because he could not imagine that any of his cabinet colleagues would take it seriously. Some commentators have suggested that in such examples there was little or no evidence of the process of parliamentary scrutiny actually fixing any of the problems with policies and legislation.
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Looked at from this perspective, the 2012 Health and Social Care Act is not so unusual. Its importance instead arises from the impact that it has on everyone living in England. Everyone will use the NHS at some point in their life, from birth to death. They expect it to be there when they need it and, unlike the situation in the USA, they take reassurance from the fact that an unexpected illness will not bankrupt them.
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So what did happen? This is something that will be discussed for many years, by policy researchers, historians and, especially, by teachers in business schools seeking case studies of policy failures. The full details may not emerge for many years, until there is publication of the minutes of cabinet meetings and ministerial biographies. Yet even now, some things are clear.

The first is that some people did have a very clear idea of what they wanted the Act to do. As we have documented previously.
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in 1988 Oliver Letwin, now a government minister, published a book entitled
Privatising the world: a study of international privatisation in theory and in practice.
The foreword was written by the prominent Conservative backbench MP John Redwood. They set out a series of goals for the NHS, including establishing it as a trust independent of government, increasing joint ventures between the NHS and the private sector, extending the principle of charging, with individuals being given personal health budgets, or vouchers, that they could top up if needed. However, they recognised
that this would be very difficult to achieve politically. As they noted:

A system of this sort would be fraught with transitional difficulties. And it would be foolhardy to move so far from the present one in a single leap. But need there be just one leap? Might it not, rather, be possible to work slowly from the present system toward a national insurance scheme? One could begin, for example, with the establishment of the NHS as an independent trust, with increased joint ventures between the NHS and the private sector; move on next to use of ‘credits’ to meet standard charges set by a central NHS funding administration for independently managed hospitals or districts; and only at the last stage create a national health insurance scheme separate from the tax system.
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Clearly, many aspects of the Health and Social Care Act would permit such developments.
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While all previous purchasing bodies, such as Primary Care Trusts, were responsible for the health of a geographically defined population, the new Clinical Commissioning Groups (CCGs) are not. Moreover, this is a change that the government was absolutely insistent upon. The only plausible reason that it held this position so strongly was to allow CCGs to change, in due course, into competing insurers, offering distinctive packages to different groups within the population. One might focus on the young and healthy, including gym membership but excluding care that would be more important to older people. Of course, some form of risk equalisation system would be introduced but, as experience elsewhere shows, those in the health care business are always several
steps ahead of the regulators. The process would be aided by the roll-out of personal health budgets. After all, who could argue with the idea that individuals are best placed to know what health services they need, and indeed this may be true for some people with multiple complex problems. However, as experiences with a wide range of financial services and utilities would have predicted and the Dutch experience with personal health budgets has shown, they also provide numerous opportunities for unscrupulous companies to exploit the vulnerable.
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Of course, the Act did not spell out this option. Indeed, it did not spell out very much at all, despite its several hundred pages. Rather, it was worded in a way that would allow such a scenario to develop, along with many others. Thus, its supporters could portray it as a minimal change from the status quo, strengthening the role of the general practitioner, while its critics could equally argue that it would usher in change on a massive scale. Indeed, those critics who were not reassured by ministerial platitudes noted the contradiction between what they were saying and the comment of the NHS Chief Executive that the reforms were so large ‘you could see them from space’.

And this is where one of the main difficulties lay. It is very difficult to write legislation in clear English when you are trying to conceal what you are really seeking to achieve. It is even more difficult when ministers draw on Lewis Carroll for their inspiration, failing to realise that
Alice through the Looking Glass
was in many respects an allegory and was certainly not intended as an instruction manual for government. We are expected to laugh at Humpty Dumpty’s argument that when he used a word ‘it means just what I choose it to mean’ and not emulate him.
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Consequently, despite a convincing
argument that what was being proposed actually met all the accepted definitions of privatisation,
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somehow this word was redefined by ministers to ignore whether health services were delivered by a public or a private provider.

This then poses a problem with implementation. Although diligent observers, sadly outside rather than inside parliament, could spot the problems, the more gullible could be reassured by bland ministerial statements that the sceptics simply did not understand the words that were used. At times, as with the Section 75 competition regulations, the dominant message seemed to be that a true understanding was impossible to those outside the priestly class of ministers and their advisors and that any fears were misplaced.
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Echoing Voltaire’s Dr Pangloss, all would be for the best in the best of all possible worlds.
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Consequently, many front line workers took these statements at face value, accepting the view that little had really changed. All that the new Act did was to make some minor changes to give the NHS some more freedom from government and give general practitioners a greater role in deciding what services would be provided. The Act emphatically did not promote privatisation, we were told. And to the extent that there would be any increase in non-NHS provision, it would be by friendly social enterprises that were close to their client base but were more flexible than traditional NHS providers in meeting their changing needs. Inevitably, it came as a surprise to many to learn that what they thought were core NHS services were instead being transferred to large international corporations, such as Serco and G4S, a process that continued even after an investigation was launched into whether they had defrauded the Home Office on offender management contracts
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and after the latter had spectacularly mismanaged security at the London
Olympics.

There is, however, a problem with this model. These large corporations work in many different sectors, from health care, to prisons, to railways, and to the management of London’s congestion zone. Their fundamental concern is the bottom line. Where can they make the largest return on investment? And they are slowly realising that this is not in health, with Serco withdrawing from the health market in the United Kingdom.
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Their entry into the market was predicated on an idea that there was massive waste, with gross overstaffing and overpaid workers. They were able to succeed to some extent in cutting salaries, thereby transferring the cost of employing people to the taxpayer who would top up their salaries in work benefits. But they were less successful in cutting numbers and reducing skill levels. Health care is a labour intensive sector and one in which skills matter. One scandal after another unfolded and it became clear that they were suffering severe reputational risk that would compromise their ability to win contracts in other sectors and other countries.
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They have also realised that the contradictions within the Act, and the resulting confusion, create further barriers to profitability.
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Instead, they have been focusing on areas where this is not a problem, such as prisons and Australian asylum detention centres where the clients are in no position to complain and can, ideally, be left to look after themselves without the inconvenience of having to pay them.
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In British politics it is very rare for politicians to be held accountable for their failures. Indeed, the few cases where this has happened tend to have involved military debacles, such as Churchill at Gallipoli, Chamberlain at Narvik, or Blair in Iraq. In these cases, the scale of the disaster was obvious almost at once and could not be concealed. The Health
and Social Care Act is more complicated. It is too easy to lay the blame on other factors, such as the economic crisis (temporarily ignoring the role that the current government has played in making it worse)
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or an aging and more demanding population. It is also easy to dictate the narrative, especially when most of the major newspapers support one of the parties that implemented the Act. In their excellent book
NHS SOS,
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Jacky Davis and Raymond Tallis took the arguments used to justify both the Health and Social Care Act and the legislation enacted by the previous Labour government that paved the way for it and subjected them to the critical examination that our parliamentarians should have done but failed to do. They demonstrated clearly the existential threat that the NHS is facing. Although he subsequently claimed that his words were misinterpreted, in 2004 Oliver Letwin was reported to have said that the NHS would not exist within five years of a Conservative victory.
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Writing in winter 2014, it seems that he will be proven wrong, but only just. The combination of austerity, transitional costs, and organisational chaos mean that the NHS is suffering almost unprecedented pressures.
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Waiting times in emergency departments are at the highest level since records began. Morale among health workers is at rock bottom after four years of pay freezes and, in some areas, general practice is nearing collapse. What is to be done?

In this new book, Jacky Davis, joined by John Lister and David Wrigley, look at the continuing threats to the NHS and demolish the myths that have been widely promulgated by those who seek to undermine it. In
Chapter 1
they set the scene, reminding us of the broad sweep of events since the passage of the Health and Social Care Act. They warn of the dangers posed by the Trans-Atlantic Trade and Investment Partnership (TTIP) to the provision of all public services,
explaining why reassurances to the contrary are at best misinformed and at worst disingenuous.
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In
Chapter 2
they tackle the claim that ‘The NHS can’t go on like this’. They remind us that, until the recent reforms, the NHS enjoyed record approval ratings. Historically underfunded compared with health systems in other industrialised countries, the injection of funds after 1999 was followed by sustained improvement in outcomes
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and it now consistently achieves some of the highest scores in international comparisons of health systems.
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The argument that an ageing population will render the NHS unsustainable ignores the simple fact that the costs of care are concentrated in the last few months of life, whenever that occurs.
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Moreover, recent research has shown convincingly that adequate investment in health is actually a driver of economic growth, not as is often suggested, a drag on it.
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It is not that we cannot afford the NHS. Rather, we cannot afford to do without it.

Chapter 3
addresses the myth of choice and competition in health care. Fifty years ago, Kenneth Arrow, a Nobel laureate in economics, showed why markets do not work in health care.
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Sadly, despite the success of the United States in proving him correct, many commentators are unable, or more likely unwilling, to understand this. As Upton Sinclair famously noted, ‘it is difficult to get a man to understand something when his salary depends on his not understanding it’.
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The reality, as is now becoming apparent in England, is that providers are choosing patients and not the other way round.