The leaked White Paper on the NHS is being spun as an end to privatisation. Health campaigner Gill George takes a closer look at a plan that gives Tory ministers broad powers to cut services and splash public money on private firms.
Nurses aren’t angels and doctors aren’t heroes. That romanticised narrative has become a cover for a decade of neglect of the NHS; for a decade of inadequate staffing, insufficient hospital beds, and an escalating funding crisis.
Every NHS worker wants the resources to do their job properly and safely, and with decent pay and conditions. That’s true for nurses, doctors, therapists and scientists. It’s equally true for the porters, cooks and cleaners in the health service. The NHS depends on a whole army of workers, people working together for a common good.
The Covid-19 pandemic has exposed some of the terrible gaps in the NHS. It shouldn’t need saying – but one ICU nurse can’t do the job of three; care on a regular hospital ward isn’t the same as being in intensive care; and being looked after at home by your partner cannot give you the same care as a hospital stay. NHS staff have worked to exhaustion and beyond – but the gaps that are there even in normal times have broadened into chasms. The under-resourcing of our NHS has cost lives.
Hurrah, then, for the Government’s new health White Paper! Carefully placed leaks to sympathetic media outlets told us of bold Government plans to end privatisation of the NHS, for the Government to have new powers to stop hospital closures, and of new plans for NHS organisations to collaborate to provide better patient care.
Unsurprisingly, the reality is as different as it could be. A draft of the White Paper is now in the public domain. There is nothing meaningful on the funding crisis or the catastrophic problems with workforce. Nothing on how the crisis in adult social care will be addressed. Nothing that will reverse the grotesque under-resourcing of public health. We should have no expectation, then, that the White Paper will solve the most pressing problems in health and social care.
An enormous expansion of NHS privatisation
What about privatisation? Interestingly, the intention is a systematic dismantling of Andrew Lansley’s 2012 Health and Social Care Act. The ideological drive behind the Cameron-Lansley legislation was that the market would provide. There is an admission in the new White Paper that this has failed:
‘The Health and Social Care Act 2012 put a regime in place which put competition as the organising principle for improvement in NHS care. This has in some cases hindered integration between providers. In practice, the NHS has not operated as the market intended by the 2012 Act.’
A key reason behind the failure of this market-driven approach was a straightforward one. The NHS has been starved of funds, year on year. The ‘commissioners’, the Clinical Commissioning Groups, have struggled to meet ambitious savings targets and have attempted to balance the books by passing on those cuts to ‘providers’ – the organisations that actually provide the care. The lack of money in the system meant that – with the exception of some niche opportunities – the private sector couldn’t make significant profits through the provision of NHS services. They backed off, and NHS organisations were left with the impossible job of juggling the needs of an ageing population against increasingly inadequate NHS funding.
The 2012 intention was undoubtedly the wholesale transfer of clinical services to the private sector. The parallel imperative of controlling costs meant it couldn’t be achieved. This time around, they’re being a bit sharper about it. Under the guise of slashing bureaucracy, and with enthusiastic over-use of the words ‘flexible’ and ‘flexibility’, the broad plan seems to be that the Secretary of State for Health can do anything he wants, and this will include chucking a lot of money at the private sector. Government plans end the market but will hugely expand the role of the private sector both in running the NHS and in providing NHS services.
Covid-19 has provided exciting opportunities to dish out lucrative contracts to friends of the Government. We can expect to see more of the same.
We are assured in the White Paper that there will be ‘an important role for voluntary and independent sector providers’. The nature of this important role is somewhat concealed, with many references to ‘others’, ‘other providers’, ‘other partners’, and ‘other bodies’. We are told of the plan for ‘health and care services, local government, NHS bodies, and others to work ever more closely together’. Behind the weasel words, the direction of travel is clear. The objective is for private sector involvement not just at the level of providing a service in line with a tightly specified contract. The ‘others determined locally’ will be part of the ‘Integrated Care System NHS Bodies’ that will determine which services will be provided and which organisations will provide them. The private sector is to be at the heart of NHS decision-making in a way that it never has been before.
The White Paper builds on earlier proposals from NHS England for the creation of 42 ‘Integrated Care Systems’ to replace the ramshackle commissioner-provider split created by the 2012 Act. These are to be set up via a ‘Health Systems Support Framework’ (HSSF). Behind the jargon is a mechanism created by NHS England to enable the rapid contracting out of £700m worth of services. There is already a pre-approved list in place of over 80 companies which will make up this ‘Support Framework’. They will have close involvement in the creation and ongoing running of the news ICS bodies. The Keep Our NHS Public briefing on integrated care comments that ‘This will put corporates at the heart of ICS management, as well as decisions about outsourcing of both clinical and non-clinical services, including the control of NHS data and digital systems, management, health planning, referral controls and clinical care pathways’.
So which companies are we talking about here? Many of the names are familiar. They’ve already made a mint out of the NHS, and many are currently getting even richer off the back of Covid-19. We have on the list McKinsey, Optum (part of United Health), KPMG, Deloitte, PWC, Ernst and Young… There are US corporations here, as well as major UK and European companies.
Again, we are to see a sharp escalation in private sector involvement at the absolute heart of the NHS. The ‘market’ will go – but will be replaced with an approach of “Come on in, chaps, the water’s lovely”. Contracts will be freely dished out, just as they have been with Covid. This is not in the interests of patients.
A US model for managing care downwards
The reality of Integrated Care Systems is at risk of getting lost behind a fluffy fudge of nice words around collaboration and joined-up care. NHS England used to call them ‘Accountable Care Organisations’ – the name has changed, but the essence of the idea is the same. The model comes straight from the United States. Sure, different organisations will work together. They will work together in an underfunded system, and they will collaborate in the dumbing down of care and the restriction of access to care. This is about cost management. There is nothing in this for us.
A postcode lottery, the loss of public accountability, and a ragbag of concerns
The creation of CCGs by the 2012 Act has created a drift towards a ‘postcode lottery’ in the NHS. This is set to get a good deal worse. ICS Boards, with their cobbled together ‘partnerships’ of whoever is around, will determine what the NHS consists of in a given area. Will your GP be allowed to refer you to a specialist? Will the specialist be allowed to refer you for a hip replacement, or will you have to jump through endless hoops and wait for three years first? Will a disabled child get support, or will they be left to sink or swim? North East London will be different to Shropshire, Telford and Wrekin,which will be different in turn to Cheshire and Merseyside. For patients, our healthcare will be determined by where we live – or by our ability to pay for private care when the local version of NHS care lets us down.
Is there intended to be any public accountability at all? Phrases around the need for ‘public confidence and accountability’ are sprinkled liberally throughout the White Paper – but there’s no hint at all of any actual public involvement or mechanism to enable influence on our healthcare.
There is a ragbag of other concerns. There will no longer be any requirement on hospitals to assess patients prior to discharge – because the new model will be ‘discharge to assess’. And discharge to assess is fine if there is robust risk assessment, and if the services needed by an individual patient are guaranteed to be in place. Without these safeguards, it’s a cost-driven process to get patients out of hospital as quickly as possible in order to free up beds. The dangers are obvious.
There is a pretence that patient choice in the NHS will be supported. We are told, ‘A patient’s right to choose where and who will provide their health and care needs will be preserved and strengthened in the new system arrangements’, and there is a bit more blather about how important choice is. There is no acknowledgement that choice has all but vanished in the NHS, and no actual plan as to how it will be reinstated or strengthened. This is just playing with words.
An additional strand of privatisation – just in case we didn’t have enough – is that the Secretary of State will be allowed to provide financial assistance to ‘any bodies which are engaged in the provision of social care services in England’. One assumes if they are owned by a donor to the Conservative Party, this will be advantageous. There are no safeguards around this. It’s the Covid approach to awarding contracts.
The proposed structures are quite bizarre, with an extra local committee – an ‘ICS Health and Care Partnership’ – chucked in alongside the key ‘ICS NHS Body’. This seems to be about a pretence that there will be actual integration of health services and social care – but it is the NHS body that dominates. And yet again, there are no proposals here for the funding of social care. The current system is not remotely working, and it will go on not working, apparently on an indefinite basis.
Political accountability – or a political power grab?
The 2012 Act was about removing political accountability for the NHS. The pretence was that NHS England was independent of government. This was never actually true, but it provided Ministers with a convenient fig leaf for pretending that problems in the NHS were nothing to do with them.
That will now end. Simon Stevens, as Chief Executive of NHS England, occasionally had the temerity to ask for more money, or to make a speech without dotting every ‘I’ and crossing every ‘t’ with the Government first. Presumably this irritated them. The proposal in the draft White Paper is that the Secretary of State for Health and Social Care effectively becomes God. The Secretary of State can take key decisions on pretty much anything, including telling NHS England what to do, and intervening directly on service reconfiguration changes.
Yes, the prospect of Matt Hancock as God is fairly scary – but the restoration of political accountability for the NHS may be important. In principle, this re-establishes that the underfunding of the NHS is the Government’s responsibility. So are the 100,000 staff vacancies in the NHS, and the shortage of hospital beds, and the woeful state of public health in England. The Government resumes responsibility, too, for the shocking tally of Covid deaths, and for the socioeconomic inequality that leads to so much ill health. Our ability to hold them to account depends of course on our strength, organisation and resolve.
The political responsibility assumed by the Secretary of State will now include local cuts and closures. Local MPs will no longer be able to hide behind a muttered comment that they have to let clinicians decide. When a hospital is being downgraded or an A&E closed, it will be the Secretary of State who has the power to decide the outcome – and we can demand that our MPs stand up for the healthcare that their constituents need.
The challenge we face is that their intention is not accountability – but the centralisation of power and control. This is meant to be a power grab. Buried in the small print of the draft White Paper is an outrageous proposal that local authorities will no longer be allowed to refer unworkable reconfiguration proposals to the Secretary of State. Their current right to do so is to be removed, in a direct and very serious attack on local democracy.
It’s important here not to be taken in by the spin. This is a Conservative Government. Of course it is not ending privatisation of the NHS; it is massively expanding it. And integrated care is a brilliant concept and a fine objective – but that’s not what this is about. The agenda here is cost control, and collaboration to drive through worse care and worse access to care.
The only possible gain for us is the restoration of political accountability for the NHS – but this opening goes hand in hand with reduced public accountability and reduced powers for local authorities to challenge reconfiguration. The outcome here depends on the balance of forces.
Campaigners in England are left with two choices now. One is to fight like hell for the NHS before it is degraded still further. The other is probably to move to Scotland!