A response to Paul Cotterill

I don't want to get into a tit-for-tat my-doomsday-prediction-is-worse-than-yours, but I thought I ought to respond to Paul Cotterill's article (@BickerRecord) on Though Cowards Flinch, The NHS is dead (part1): facing facts. Paul has got the facts right, but he's only talking about one part of Lansley's policies. I don't blame him for this, just about every one does, and when I give talks about Lansley's policie the first thing I do is set people straight: commissioning is not the chief problem, the problem is what Lansley is doing about providers. In other words, look away from GPs and look towards hospitals and community health services.

Paul takes a gloomy attitude that the NHS is already lost. I beg to differ, he may be right about some GPs (though not all) wanting to profit from commissioning, but he's only looking at part of the service. So while half may well be a "done deal" the other half of the policy has not started yet, and there are still many people in the NHS willing to fight to stop that part of the policy being implemented.

Lansley is already implementing some of his Health Bill proposals (without Parliamentary approval) by creating the GP commissioning Pathfinder consortia, and through these, make PCTs irrelevant. This is a one way process: re-creating PCTs would be extremely expensive, so it is better to constructively amend what is happening rather than to oppose it altogether. If the Health Bill was binned today even the most enlightened and public service orientated Health Secretary would not want to try and re-create PCTs.

I do not oppose GP being involved in commissioning, and most patients when asked if they would like their GP to decide about how their care is delivered they would also agree. Lansley knows this, and this is why he only talks about GP commissioning and "patient choice". His argument against his opponents are that they do not want "patient choice" and that they do not want GPs to be involved in designing patient care, both powerful political arguments. The problem is how Lansley is implementing this policy. Cumbria has had GP commissioning for a couple of years, but the significant point is that this relied upon the help from the PCT rather than the abolition of the local PCT: it worked because of collaboration with the PCT rather than in spite of it. (The opposition has failed to make enough capital out of Lansley saying before the election that GP commissioning would involve PCTs and then his sudden decision ten days after the election to abolish PCTs.)

My main objection to the abolition of PCTs is because they were a layer that isolated GPs from the cash. This, to me is the most important thing because I want my GP to make decisions about me purely based on clinical decisions. However, the White Paper (section 5.12) gives Lansley's attitude towards healthcare:

"GP consortia will align clinical decisions in general practice with the financial consequences of those decisions."

This statement thrusts a rusty blade of commercialism right into the beating heart of our NHS. GPs are being told by Lansley to view their patients as customers. There are two aspects to this. First these "financial consequences" may mean an income stream for the GP (directly or indirectly): a positive aspect for those GPs wanting to make a lot of cash (Lansley calls this "innovation"). But second, these "financial consequences" also mean rationing: the negative side, the side that GPs do not want to do, and patients wish did not exist. We all know that rationing occurs in the NHS, but we know that through clinical decisions (and the evidence-based policies of NICE) the rationing occurs on a basis of what is best for the patient and the community as a whole. Under Lansley's plans a patient can simply become too expensive for a GP practice.

Paul says that GP consortia won't use PCT commissioners and instead will resort to private companies. I agree that this has happened, but I doubt if it will be widespread. There is too much institutional memory within the current PCT commissioners and the knowledge they hold is valuable. Many of the "pathfinder" GP consortia are either existing Practice Based Commissioning groups or collections of PBCs. PBCs are geographically based and associated with PCT boundaries, thus PCT commissioners know the PBCs, and have had years commissioning for them, and so it would be a natural move from the PCT to the PBC GP consortium. A private company will not necessarily have the local experience. GPs are cautious, they understand that if commissioning goes wrong the consequences are dire (in particular, but not exclusively, the "financial consequences"), so they are more likely to take an attitude of "better the devil you know", and that is the PCT commissioners

However, the smaller GP consortia are an issue, because the income the receive may not be enough to employ the commissioners they need. These consortia are likely to either cluster with other consortia (in which case, why be separate?) or buy-in the commissioning. (See here for an analysis of the consortia sizes.) Lansley's number one mistake was not giving any guidance at all about GP consortia size and location. Although there will be a huge upheaval in the run up to PCTs being abolished, there will be years and years of upheaval as the smaller GP consortia merge (as they come to terms with the fact that "small is beautiful, but financially unsustainable"), and the large consortia break apart. In a decades time we will achieve a steady state: but at what cost to healthcare?

Paul says that the private commissioning companies will maximise their profits "firstly by focusing entirely on the core business of purchasing secondary care, to the exclusion of all other considerations around preventative and public health". Well, since public health accounts for just 3% of the budget it is not surprising that it will take a back seat. Here are figures from my local PCT (and I guess they are representative): Acute care 49%, mental health 8.7%, community services 7.2%, continuing healthcare 6.4%, primary care 23%. Incidentally, that 23% for primary care is roughly half for GPs and half for "additional GP services". This latter part is important because it is work that used to be carried out in hospitals but is now done by GPs. It is a sector that will increase dramatically over the next few years (remember what I said above about what GPs will see as the positive side to "financial consequences"?).

However, GPs will not be allowed to ignore public health. The Health Bill specifically says that GP consortia will be held to account for the health inequalities and outcomes in their area (they will have to produce strategy documents on these, and will have to provide annual reports indicating how successful they have been). Whether this will be a paper exercise or not is yet to be seen, but I can assure Paul that the Bill has addressed the issue. The Bill also gives local authorities more responsibility for public health, and again, it is unknown whether this will be successful.

Paul then says:

"Second, they will purchase as much private healthcare as they can, and the percentage of the care bought from the private sector will increase dramatically within a year or two.  As state hospitals lose their business, they will close or – more likely in the shorter term – be bought up lock, stock and barrel by the private hospital operators."

I think that the situation is far more complicated than this. First, there is not the capacity in private hospitals at the moment, and there is not the money for those private companies to invest. For example, today I heard that profits at BUPA "tumbled 72% to £118m in 2010", BUPA are not doing well, so how will they expand their hospitals to take on the nuge numbers of NHS patients Paul suggests? The US company Humana has even pulled out of the UK because they are "unconvinced that Andrew Lansley’s plans to hand over the commissioning ... to GPs in England will necessarily open up a lucrative market in commissioning support". So I am not convinced that the numbers of patients sent to private hospitals will rise dramatically. (In any case, the NHS has been outsourcing a lot to private health care over the last decade, can the rate increase more than it is now?) Second, there is not the expertise: the vast majority of consultants in the country are NHS-based, and the private sector gets their expertise from these clinicians. Herein lies the actual threat.

Cameron announced a few weeks ago that

"We will create a new presumption – backed up by new rights for public service users and a new system of independent adjudication – that public services should be open to a range of providers competing to offer a better service."

Note that there is no mention of "patient choice", patients cannot choose to have a public provider, instead David Cameron will allow private providers to choose what services are available for the patient, through this new "presumption" that they will be able to take over NHS services. In practice, what this means is a private provider (or a collection of existing NHS consultants grouped as a company) can insist that they provide a service at an NHS hospital. The white paper (section 4.28) says that Monitor (the super-powerful economic regulator and headed by an arch-privatiser) will:

"require monopoly providers to grant access to their facilities to third parties"

The "monopoly providers" are NHS hospitals and the "third parties" will be these new groups of consultants. Think about it: there will be minimal start up costs to these companies and all the consultants need to do is get together and say to a hospital "we are now an Any Willing Provider for this service". In the future your NHS hospital will be run like a department store with "franchises" of Any Willing Providers running the facilities and providing the services.

Paul then makes the accusation:

"Insurance-based healthcare, and the exclusions that this brings, will come not through a government announcement, but by the surgery backdoor."

I disagree, it will come through a government announcement. First, let me give some background. In 2005 in the Independent Nick Clegg (the collaborator and traitor he is) said:

"One very, very important point - I think breaking up the NHS is exactly what you do need to do to make it a more responsive service." Then he goes further, even refusing to rule out the insurance-based models used in mainland Europe and Canada.

"I don't think anything should be ruled out. I think it would be really, really daft to rule out any other model from Europe or elsewhere. I do think they deserve to be looked out because frankly the faults of the British health service compared to others still leave much to be desired."

It frankly amazes me that anyone wanted to vote for this Hannan-esque monster, but that, sadly, is history. It is clear, however, that part of the government (the Orange Bookers) want to kill the principle of "free at the point of use".

On the other hand, Lansley constantly says that the NHS will be "free at the point of use, based on need, not ability to pay". I happen to think that Nick Clegg said what Lansley believes, but through political expediency Lansley has to continue to quote the NHS mantra "free at the point of use". Health insurance will come through a different vector.

At no point has Lansley ever said that he will outlaw co-pay. It has not been talked about. Curious, eh? I mean, if the NHS is costing the taxpayer too much, why not ask for a reasonable contribution from the patient? We already have this in dentistry where you are offered private care as well as NHS care, and it happens in social care too (councils means test vulnerable people and then impose a standard charge which is a contribution to, rather than the full cost of the social care they receive). We have a form of co-pay with prescription charges, so why not apply a co-pay commitment for NHS treatment too?

As rationing starts to get bad (and it will) the middle classes will clamour for co-pay. The current rules say that if you pay for a drug that you need for your treatment then it means that you are receiving private care and so you have to pay for all of the NHS care. This is right. If there is a clinical need for the care then the NHS should provide it. NICE was created to identify what was clinically required, and hence what the NHS will pay for. Lansley's policy is to neuter NICE, it will be merely "advisory". It won't be too long before patients feel the effects of rationing and the postcode lottery.

In a few years time, to placate the middle classes affected by the postcode lottery, Lansley will sanction co-pay, he will say that those who can afford to pay extra will be allowed to. We will see co-pay introduced into primary care first, followed by acute care.  Of course, not everyone can afford co-pay, and this will result in insurance companies providing products where the middle classes can pay an affordable monthly premium so that in the event that they need to pay for NHS co-pay the insurance company will provide the payment. (This is not what Americans regard as co-pay: to them co-pay is more like the car insurance excess that we pay; insurance pays the majority but patients are expected to pay a contribution out of pocket. What I am talking about is a top-up contribution, for patients to get extra care.) Indeed, the BMA consultants conference even voted that NHS patients should be allowed to pay "top-ups" in 2008 (how times have changed). Once Lansley sanctions co-pay, health insurance will follow.

Paul's article, like most people, ignores the policy of Any Willing Provider, and the effect this will have on NHS hospitals. This is the most significant part of Lansley policy and GP commissioning is minor compared to it. Lansley sells the policy as patient choice, but it is clear that it really is commissioner's choice: patients will not get to choose. Further, it has become apparent that the privatisation will be imposed top down. Yesterday Pulse magazine reported that the SHA in the East of England was designing integrated care pathways that used private companies. The SHA is a level above PCTs and their work in future will be provided by the soon to be constituted National Commissioning Board. It is clear to me that the NCB will impose privatisation top down onto GP commissioners through AWP.

Prof Chris Ham from the Kings Fund writing in the BMJ says:

"Although many organisations have focused their attention on plans to give general practices a major role in commissioning health services and to require all NHS providers to become foundation trusts, these changes are of secondary importance compared with the radical extension of competition in healthcare."

It is clear to me that the main focus of any opposition to the Health Bill should be focussed on the policy of Any Willing Provider.

Paul's article is announced as the first of two parts, and

"If I get round to a part 2, I’ll cover some things the Left and Labour still can do, but this will be with a mind to strategy, not pointless posturing (so I don’t suppose anyone will take any notice)."

Well, I have already covered what Labour should do in an article on Liberal Conspiracy and on this blog:

And one final point. Ed Miliband must pledge that Labour believes that hospitals and community health services should be publicly owned. Drop the "mutuals" idea because this is too close to Lansley's "social enterprises" idea. NHS hospitals should be publicly owned, publicly run and publicly accountable. Is that a simple enough message for Ed to understand

The battle in the future will be about keeping our hospitals publicly owned. I hope that Paul gets round to his part 2, and I hope that he follows my lead.