Is This the End of the NHS?
|Author: Susanna Rees||Published: 15th February 2012 11:29|
Neston resident Susanna Rees reports on a public meeting held to discuss the proposed Health and Social Care Bill.
It was a very good talk given by Dr Christopher Birt on the NHS reforms on Tuesday 7 February and quite different from the previous talk by Jonathan Folb.
Chris Birt set out the nuts and bolts of the Health and Social Care Bill and what it means for the NHS. The title of the talk was: Is This End of The NHS?
Chris Birt is a public health physician for Sefton Primary Care Trust (PCT) and the University of Liverpool. Public health is about preventing and managing disease, injury and health conditions by monitoring sickness and encouraging healthy behaviour, communities and environments. For ten years he was Director of Public Health for Stockport. His special areas of interest are cardiovascular epidemiology and prevention and public health at European level. He was until last year Co-Chair of the Board of Trustees of Heart of Mersey, a charity that is the UK's largest cardiovascular disease prevention programme, operating across Cheshire and Merseyside.
Chris looks and sounds formal and professional. He had a PowerPoint presentation and at first it looked as if the talk might be heavily technical because it was about NHS structures - but he did that to put people in the picture and then he started on the detail and it was devastating.
He was not hopeful. He thinks that we won't see the change straight away but in about ten years it will be a commercial USA-style healthcare market. Point by point, in a very dry and academic and unemotional way, he set out what he thought is going to happen.
The talk began by setting out the background to the Health and Social Care Bill: that in opposition David Cameron promised "no more top down reorganisations of the NHS" but then in the summer of 2010, just after the election, proposals were published for the most major restructuring of the NHS since 1948 and this was sold as "handing control of NHS back to clinicians".
He outlined the proposed changes: the Strategic Health Authorities (SHAs) and Primary Care Trusts (PCTs) are being abolished. The Public Health organisations will be split up and the job of explaining public health initiatives will be given to local authorities (councils), to be centrally directed by a new government body called "Public Health England". Protecting public health will be centralised. Local healthcare services will now be organised by local groups of GPs called "Clinical Commissioning Groups" that will choose and buy in healthcare services from the NHS and from private providers who work privately but under the NHS logo so you won't be able to tell that they are private companies - this happens already. The Clinical Commissioning Groups will work in groups of anything from eight to forty GP practices and will be overseen by a national "Commissioning Board". A new health regulator is being set up called "Monitor".
He set out four immediate problems within the Health and Social Care Bill as originally presented:
- The Secretary of State will no longer be responsible for providing all services on an equitable (fair and equal) basis to the whole population (so he will no longer have a "duty to provide" comprehensive healthcare covering everything for everybody but will only have a duty to promote a healthcare industry);
- "Commissioning" will need more than just GPs to do it - they will need advice from nursing, therapists, public health, accountants, lawyers and many others;
- Most local GP groups will be too small to be effective "commissioners" as they will not be able to deal with all of this complexity;
- The "risk register" setting out the risks to patients and to the finances and stability of the NHS of the proposals for NHS reform has not been published although the Information Commissioner has ordered the Department of Health to publish it. The Department of Health continues to refuse to disclose it, saying that the Risk Register contains sensitive information that might stop the Bill passing through Parliament: releasing the risk register would have "jeopardised the success of the policy". (The Information Commissioner says that the Department of Health has now twice broken Freedom of Information law in refusing to disclose it.)
He saw some serious consequential problems which would threaten the future of the NHS as we know it:
- Large confederations of local GP groups will be responsible for "commissioning" and may use commercial firms as contractors who will do this for profit - so their profit must be taken out from the healthcare budget and will not be spent on patients;
- Secondary care (where you are referred to a hospital or health team for treatment by your GP) may be commissioned from "any willing provider", with no respect for quality of care, price being the deciding factor - so your doctor is being instructed by government to pay more attention to price than to quality;
- Clinical Commissioning Groups will not be responsible for a defined geographical area, such as a town - so there will be no guarantee of equality of access to care for all - in other words doctors can treat anyone from anywhere but you will not have a right to be treated where you live - doctors won't have to treat you just because you live in the town where their practice is and you may have to find a GP out of area if your local GP practices are too popular. This turns GP practices back into businesses competing with each other on an open market for patients from all areas, as they were before the NHS began, and breaks a strong link between the public and the NHS as a local service available for all.
- There will be no guarantee of provision of services in relation to need - in other words planning will follow demand (so what people say they want will be used as evidence for funding, rather than more scientific estimates of need, which the market may miss entirely (for example screening new born babies for thyroid disease).
He identified some likely adverse outcomes:
- Commissioning by GPs will be governed by profit, and no longer by need. The emphasis will be on acute emergency services so long-term ongoing chronic conditions, which are expensive in the long term, but not "dramatic", will take lower priority than acute emergency conditions and elective surgery (that doesn't involve a medical emergency) - he wondered what will be the future for services for the elderly, for the mentally ill and the disabled;
- Not all of the services that we need will be accessible to everyone;
- Health inequalities of all kinds will widen;
- Training arrangements (for doctors and nurses) will be severely threatened;
- The number of tiers of management appears likely to increase - he thinks this will be "a field day for finance officers".
He looked at the concessionary amendments that have now been proposed in the House of Lords. If these go through then:
- The Secretary of State will have some (reduced) responsibility to provide healthcare services;
- Healthcare services will be commissioned taking account of quality as well as price;
- There may be some guarantees that much work would continue to be provided by NHS acute trusts;
- There may be partial guarantees that public health departments will be able to functions much as they have until now in PCTs
- Monitor will now seek to coordinate more integrated services - it is not quite understood what this means in practice.
He suggested that we try to look forward:
- If all of this goes ahead, changes will occur slowly, but in 10 years there may be no recognisable NHS;
- What remains may be a "poor service for the poor" and those who can afford it will be expected to take out private insurance;
- The effectiveness of NHS services will be reduced (to the levels experienced in the USA - it is surprising to hear this but the NHS internationally is a very high performer - you would not receive the same level of care in the US for what we spend per head in the UK, but NHS costs are likely to rise because of commercial overheads of the new private providers as well as the increasing costs of new medical technologies;
- Meanwhile Scotland, Wales, and Northern Ireland will continue to enjoy the NHS as the English once knew it!
And finally he suggested that we stand back and see the bigger picture:
- The stated philosophy behind the Bill has much to commend it;
- But it could be achieved without any enforced restructuring;
- Is it too late to stop this disastrous Bill?
- Alternatives to the Bill are: the Roy Lilley solution and the Kieran Walshe proposals;
- The Royal Colleges are (at the 11th hour) mobilising.
Someone asked why had the doctors not done anything about the changes a year ago and he said that they were all too busy with their jobs and nobody had really had a clue and now at the eleventh hour doctors and health professionals have begun to try to make sense of what is being planned - because they have begun to realise that it will directly affect how they work - and they think it is the end of the NHS as we know it. He said he was very worried.
Someone asked him was he doing this on behalf of the NHS or who did he represent? He said that, although a member of the NHS Consultants Association, a Fellow of the Royal College of Physicians of Edinburgh, a Fellow of the Faculty of Public Health, and a Collegiate Member of the Royal College of Physicians of London, he was speaking for himself and had no particular axe to grind for any other particular organisation.
It was devastating because it was very clinical and objective and unemotional. This was someone from the establishment talking. You could have heard a pin drop as he talked.
He had a mass of applause at the end.
So what now?
There is a further meeting scheduled in Neston for anyone wishing to find out more. It will take place on Monday February 20th, 2pm at Neston Methodist Church. More details here.
Public pressure group 38 Degrees is encouraging everyone to sign the DirectGov petition to force a review of the Health and Social Care Bill. Sign the petition here.