p.148~154 References in the original.
Within the BMA a strong challenge emerged to the leadership’s position of ‘critical engagement’ with the government’s plans, and a demand for outright opposition. The development of serious opposition from a large part of the medical profession, and especially from GPs , was significant, because Lansley constantly claimed to have their support.
The false case for the Health and Social Care Bill
The government’s claim that the NHS was in urgent need of further fundamental reform was also becoming more and more obviously false. During the previous ten years, while the NHS was being covertly marketized, the Labour government had raised NHS funding rapidly towards the average level of spending of the other major countries of Western Europe. Spending on the NHS still remained significantly below that of the richer EU nations, and a significant portion of the new funding was absorbed by the cost of market creation. But the extra cash also produced some important improvements. Staff levels were improved, waiting times for elective care were sharply reduced, facilities were renovated or replaced.
This was reflected in the high marks given to the NHS in the Commonwealth Fund report cited in chapter 1. And by 2010 the particular charge constantly made by the marketizers, that England lagged behing European countries in the survival rates for major killer illnesses, was ceasing to be true. Lansley repeatedly declared that a wholesale restructuring of the NHS was ‘a necessity, not an option’, and David Cameron asserted that ‘pretending that there is some “easy option” of sticking with the status quo… is a complete fiction’. But in January 2011, coinciding with the publication of the Health and Social Care Bill, a paper by the King’s Fund economist John Appleby, published in the BMJ, showed tha t the marketizers’ charge was unfounded. It turned out to rest partly on the use of European data that were not comparable with the English data (and in some cases highly unreliable), and partly on selecting static data instead of trends over time. For several of the conditions usually cited English survival rates have in fact been improving so fast over the last 30 years that if the trends continue they will overtake
European rates by 2012.
The real choice
The choice is not between change and no change. It is between handing over a public service to be developed by private enterprise in the interests of shareholders, and ensuring that it develops in the interests of the public – and as the public sees those interests, not as politicians declare them to be. To maintain that there is no capacity for improvement within public provision is empty rhetoric. What evidence is there that public servcies are incapable of change and improvement (provided they are not undermined by financial starvation or market-driven disorganization)?
Around the world there are various examples of excellent public and publicly-provided health services, and all of them need to be studied for ways to improve the NHS in England – and beginning with an examination of those that are developing within the UK itself. The national media largely ignore what occurs across our nearest borders, but what is happening there, and especially in Scotland and Wales, raise crucially important questions about the future now being charted for the NHS in England.
Looking at Scotland
Even before devolution health ministers in Westminster had been too aware of Scottish sentiment to risk pushing the internal market very far there, and the Labour-Liberal Democrat coalition governments that held office in Scotland after devolution, from 1999 to 2007, recognised that voters would not support them if they followed England’s path to a healthcare market. Scotland’s Area Health Boards remained in place, foundation trust status was not introduced, nor was payment by results. The PFI was used for three Scottish hospital-building schemes, and one Independent Sector Treatment Centre was opened at Strathco in Angus. But these measures provoked intense controversy and in 2003, responding to pressure from both doctors and the public, the coalition government ended the purchaser-provider split, restoring direct administration to the NHS in Scotland and decisively closing off the market option. Also in response to public opinion, in 2002 the Scottish Labour-Lib Dem coalition made personal care for the elderly free, instead of means-tested as in England.
The 2007 elections, however, led to the formation of a minority SNP government, and yet further departures from the market-driven policy that was being pursued in England. In 2008 hospital car parking charges – a significant deterrant for families – were abolished, except at PFI hospitals, where legal reasons prevented it; and in 2010 plans were announced to abolish prescription charges from 2011. No further PFI schemes have been undertaken. Glasgow’s biggest acute hospital is being built with public funds, the ISTC at Stracathro was taken into public ownership, and plans to outsource the management of a health centre in Lanarkshire to a private company were dropped. Out-of-hours care is publicly provided.
Perhaps most significant of all for the future, in 2009 elections were introduced for the majority of the members of Scotland’s Health Boards, beginning with two pilot schemes to be evaluated after four years. This means that in addition to professional medical judgement democratic representation, rather than individual ‘patient choice’, could become a significant element in determining the direction of future change.
In face of all this the marketizers inevitably portrey Scotland’s NHS as a failure, with the usual misuse of statistics to support their claim. For example they routinely state that Scotland’s waiting times are worse than England’s, because no element of competition has been introduced into Scotland’s. In fact an analysis of newly-consolidated data concludes that since 2005 waiting times have fallen faster in Scotland than in England. In each year since then Scotland has actually had either the second shortest or (more often) the shortest waiting times of the four nations in the UK. And over the ten years from 1999 to 2008 Scotland’s mortality rates for all causes of death declined almost exactly as fast as England’s. As Dr Matthew Dunnigan, the author of the waiting times analysis, says, the objective comparison of English health statistics with those for the three devolved nations is now a very important task.
Looking at Wales
The story in Wales has many similarities to Scotland’s. For the first eight years following devolution a Labour minority government was in office, only giving way to a Labour-Plaid Cymru coalition in 2007. But as in Scotland, even the initial Labour-led Welsh Assembly Government did not dare follow the English path. The purchaser-provider split remained, but Wales did not adopt foundation trusts or payment by results. Development remained based on collaboration and planning, rather than on a market system with legally enforcable contracts and all the tensions and extra administrative costs involved.
And after 2007, under the Labour-Plaid coalition, the purchaser-provider split was dropped. In 2009 a major reform resulted in the formation of just seven integrated Local Health Boards to plan and operate the NHS in Wales. These are very like the Area Health Boards in Scotland, but also have overall responsibility for all aspects of health, including public health, with a strong emphasis on linking health and social care.
The Local Health Boards in Wales are not elected but they must have members representing local primary care, community care, public health, local government and voluntary organizations, as well as lay members. In one Local Health Board (Powys) the purchaser-provider split was abolished earlier and the Board was integrated with primary care and community health service providers. Other Boards are set to follow suit – exactly the opposite direction of change from that taken in England, where even community health services have been forced into the marketplace.
Wales also declined to use the PFI for hospital-building, led the way (in 2007) in abolishing prescription charges, abolished hospital parking charges, and dealt with the vexed issue of means-tested personal care for the elderly by widening the definition of what is considered nursing care (and therefore free), and by setting a flat-rate contribution to the cost of personal care throughout the whole country.
Considerations for England
We need to ask ourselves why Scotland and Wales opted to keep the NHS as a public service, and even extend the principle of free acess. Longstanding Scottish and Welsh cultural traditions are certainly important, especially a deeply-embedded commitment to social democracy in public life, and in the medical profession, which politicians of all parties have to respect. But another key reason is cost. Next to education health is by far the most important and expensive devolved publis service. Even before the financial crisis politicians of all parties in Scotland and Wales realised that if they followed the English route, and allowed the costs of operating a market to start soaking up ten per cent or more of the health budget, health services would be liable to deteriorate, with dire political consequences for themselves.
They know that the public spending cuts imposed by the government in Westminster will hit Scottish and Welsh health services. But they also know that the effects will be smaller that they would have been had they opted for a market, and that whatever they have to do will have a legitimate foundation in public opinion, which remains at the base of decison-making about the NHS in both countries. And when the crisis has passed they will still have a public health service, not a three-tiered healthcare market and a low-risk playground for healthcare corporations and ‘doctorpreneurs’.
Scotland and Wales don’t exhaust the alternatives for the future in England. Other good models of publically-provided health services exist and deserve study. But the successful evolution of the NHS in the rest of the UK shows that Cameron’s assertion that ‘we can’t afford not to modernise’ – meaning that we have no alternative but to accept the abolition of the NHS as a public service – is pure bluster. It has no foundation in evidence and serves no interest except that of the private health industry. In the parts of the UK that the plot against the NHS couldn’t reach, people see through it. They know that good health care for all means excluding profit-making, and have shown that with sufficient public backing that principle can prevail. We need to insist that in England too the NHS is not for selling.