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Reason for the Reorganisation
The point that government leaders are constantly making is that
the NHS has to be changed because it has been doing so badly. A
recent analysis reported showing the NHS is one of the best health
services in the world undermines the Government's argument for a
massive reorganisation. The recent
Commonwealth Fund survey ranks the NHS highly on a range of
measures looking at how health systems deal with people with chronic
and serious illness. Of 11 high income countries surveyed it finds
the NHS provides the fastest access to GPs, the best co-ordinated
care, and suffers from the among the fewest medical errors.
The success of the NHS stands out despite the fact that per
capita health spending in the UK is low at £2,170 per head, compared
with £3,200 in Switzerland and £4,950 in the US. The study
undermines the Government's rationale for embarking on such an
ambitious reorganisation of the NHS.
The original government proposals
Click here for an excellent New England Journal of Medicine view of the
proposals, summarised in the table (above).
One central question is whether abolishing two tiers of NHS
bureaucracy will actually cut management costs. The two tiers were
involved in planning, funding and organising the NHS, the third
largest organisation in the world. General Practitioners have
virtually no planning, funding or management training, so will have
to buy in those services. The way the
GP commissioning groups or consortia are progressing it looks as if
England will eventually have between 300 and 350, this is about half
the number originally envisaged by the government, who aimed to have
a consortium for every 100,000 of the population. The lower tier
which is being abolished consists of 150 Primary Care Trusts (PCTs).
These were merged from about 300(!), by the Labour Government three
years ago in order to cut management costs. The reason the consortia
are bigger than was envisaged has to do with managing risk. It only
requires a couple of patients with really complex problems in a
small organisation to bankrupt it. The larger the organisation the
more likely it will be to have average costs.
As for bureaucracy, any organisation,
especially one dealing with large sums of money will require
managers. At the least each organisation will require a person to
manage finances, human resources. Just understanding to incredibly
complicated way the GPs get paid takes more management. The public health function,
involved in planning and ensuring quality, was also held at
PCT level and will move to local authorities. Is this an example of
moving their costs to a different vote head?
Other important questions are; will the new consortia inherit the
deficits held by the PCTs? It will not cheer them up to have huge
bills to start with. Who do these consortia belong to? GPs never
joined the NHS in 1948, being 'independent contractors'. This was
largely a tax dodge for many years, but they are very keen on
keeping this status. Will this change, or will any profits go into
your local GP's retirement fund?
Allyson Pollock a well-known activist in fighting the
privatisation of the NHS has a detailed critique
here.
The reforms have now (Sept 2011) been passed after considerable
amendment but the BMA still has considerable concerns and hopes to
derail the bill in the House of Lords. Their three main areas of
concern are:
- Inappropriate and misguided reliance on market forces
- Unintended, knock-on impacts with longer-term consequences
such as the impact on public health and medical education and
training
- Over complexity and bureaucracy following recent changes to
the Bill
Some history and further background:
The
internal market or managed competition is
‘a beautiful animal in fairyland but unseen on earth’- a unicorn,
said Representative Pete Stark Chair of House of Representatives
Committee on Health, in 1993.
In 1920 the Dawson council suggested the
development of preventative and other services around health
centres, some to be designated as primary centres, others
secondary. Primary health centres would be run by general
practitioners with some assistance from visiting consultants and
would deal with the simpler cases. Complicated illnesses would be
sent to the secondary health centres staffed by consultants and
specialists. The development of such community
based health services was to be
suggested at regular intervals over the next 90 years, including by
the present Coalition government.
All hospital
trusts are also to be given Foundation status, allowing them much
more freedom to make their own decisions. There are suggestions that
local units should have more control over training and education.
This can be a concern, for, in the past, some hospitals have
invented their own grades of doctors, who may not have had the
rigorous training normally required for a standard grade.
The BMA have come out with a paper on the
proposed changes,
click here.
Scroungers
 I see scroungers are back, in the guise of 'people who make a
lifestyle choice not to work'. I wonder if Mr Cameron remembers the
words of Alfie Doolittle. 'We undeserving poor needs more than the
deserving. We eats more and certainly drinks more than the
deserving'.
The Beveridge Report, in 1942, identified five "Giant Evils" in
society: squalor, ignorance, want, idleness and disease. The
Chancellor of the Exchequer, true to form for Chancellors through
time, believed the Report to be "ambitious and involv[ing] an
impracticable financial commitment" and therefore publication should
be postponed. However the Cabinet decided to publish it.
Interestingly the Labour Party were initially against it, but the
ground-swell of public opinion and some Labour back-benchers
overcame their concerns. There have been a huge number of additional
reforms to the Welfare State since. Click here for a useful
time line.
There is a feeling from this line that the politicians early in
the century were altruistic and positive about what they were trying
to do, whereas later there was a feeling of niggardliness about
their approach.
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