Ahead of the publication of the Health and Social Care Bill this Wednesday, unions representing workers across the NHS have used a strongly-worded letter to the Times (paywall) to warn that the planned reforms are “extremely risky and potentially disastrous”. The unions (BMA, RCN, Unison, Unite, RCM and CSP) between them represent the majority of the 1.4 million people working in the NHS in England, including doctors, nurses, midwives, health visitors, psychologists, physiotherapists and many more. They argue that the current proposals could damage the quality of care and hamper effective collaborative working. The nature of the changes, the speed and scale of implementation, and the requirement to make £20 billion in savings at the same time all add up to a potent cocktail of risks.
In a speech and interview this morning, the Prime Minister defended the Government’s plans for public service reform, especially in the NHS. On the Today programme this morning (listen here or see 08.53am on the Guardian blog for a summary), he argued that the reforms were not about saving money, but about improving health outcomes and patient experience. He also insisted that the reforms were not about ideology. These themes were repeated in his speech later in the morning and deserve some further exploration.
On the first point, it is worth a more detailed look at the concerns set out by health professionals including health unions (most have their responses on their websites) and the NHS Confederation. Virtually all of these are ultimately about the impact the changes will have on patients. For those interested in finding out more, I would recommend a look at the detailed responses to the white paper by unions and other health organisations – most are available on their websites.
They argue that the marketised vision of the NHS set out in the Government’s proposals will affect patient care by putting different parts of the health service in competition with one another, leading to fragmented and disjointed pathways of care for patients and undermining collaboration and the sharing of best practice. It will also increase administrative and other costs, with public funding being wasted on transaction costs instead of patient care.
The private sector has a record of failing to deliver quality and value for money in the NHS – perhaps most famously evidenced by the rise in hospital infections after compulsory competitive tendering led to the outsourcing of hospital cleaning in the 1980s. As today’s letter says:
“There is clear evidence that price competition in healthcare is damaging. Research by economists at Imperial College shows that, following the introduction of competition in the NHS in the 1990s, under a system that allowed hospitals to negotiate prices, there was a fall in clinical quality. With scarce resources there is a serious danger that the focus will be on cost, not quality”
Much of the focus of controversy has been the plan to hand £80bn of NHS funds to consortia of GPs in a fundamental re-shaping of the way services are commissioned. But other major changes signalled by the reforms could also have wide-ranging effects. One of these, also highlighted by the joint letter, is the plan to allow “any willing provider” to compete to provide NHS services, with the NHS no longer being the preferred provider. It will ensure that private companies can bid for services – and at below the current mandatory tariff. Again, the ultimate impact will be on patient care, with the danger of a race to the bottom, fragmentation in provision and problems with workforce planning for providers who don’t know from one year to the next whether they will be providing a service.
The financial pressure on hospitals and the removal of the cap on how much private income a hospital trust can make presents the frightening scenario of a two (or more) tiered system, with NHS patients pushed to the back of the queue in favour of patients who can pay for care.
A recent NHS Confederation report also questions the weak accountability mechanisms set out in the white paper, asking how quality can be maintained in the context of price competition and saying it is unclear whether the proposed measures to regulate quality will be sufficient.
The Prime Minister’s second point was that the changes are not being driven by ideology. But if the evidence does not suggest that they will improve quality of care, and the upheaval of implementing the reforms will cost up to £3bn rather than save money, what other reason is there? As the NHS Confederation said, with some restraint: “The absence of any compelling story about why the reforms are necessary or how they will translate into improved outcomes is of concern”.
Anyone in doubt about the overall vision for public service reform under the Coalition government could do worse than look at the call for evidence on public service reform that was quietly issued at the end of November, with a 5 January deadline for responses. The paper asks a series of quite specific, detailed questions about the implementation of changes to public services. But it did not seek public input on the issues of principle and ideology that sit behind the reforms. Starkly set out in the paper, this is that the state should no longer be the ‘default provider’ of public services and that there should be a far greater role for private and voluntary sector providers, with market mechanisms determining their involvement and providing a market with ‘free entrance and exit’ for providers, and the Government setting proportions of public services that will be delivered by non-state providers. A White Paper due in February will pull these ideas and more together, but with the Health Bill and next week’s Education Bill, they already seem to be charging full steam ahead.