Under pressure from the BMA over concerns that the NHS is heading for a price-war, the Government has amended the Health Bill and removed references to the tariff paid for different services being the ‘maximum price’. This would have allowed private companies to undercut the NHS by cherry-picking easy cases. The price regulator Monitor can still ‘specify different prices for different providers’ based on ‘unavoidable’ cost differences. But it supposedly can’t mimic the absurdity of the Labour reforms and pay private companies more than the NHS to bribe them to take over services.
The BMA’s initial stance on the health reforms was ‘constructive engagement’, having been seduced by the idea that clinicians (especially GPs) would be leading the NHS. Alas, most GPs aren’t keen to be the whipping boys for a very optimistic £20-billion savings programme that will force them to openly ration services. Health Secretary Andrew Lansely’s safety net is to open up the NHS to ‘any willing provider’, and if GPs don’t take up the mantle of commissioning and providing health services, there are plenty of private companies who will. Under pressure from its membership, the BMA has become increasingly hostile to the ‘marketization of the NHS’ and held an angry meeting to debate the reforms on March 15.
These are old arguments, dating back to the Tory’s purchaser-provider split over 20 years ago, and Blair’s subsequent attempt to introduce the ‘constructive discomfort’ of competition into a bloated, self-protective, patchy quality NHS. The BMA has too many vested interests to list, but the evidence strongly suggests that price-competition in healthcare only works if you’re buying stuff (curtains, beds, machines that go ping) rather than services. Treatment is now so complex, from home to general practice to hospital, that collaboration rather than competition is far more likely to improve the NHS. Different bits of the service working in silos, not communicating and obsessed with protecting their pot of money gives you a crap, disjointed service.
Health secretary Andrew Lansely is an identikit Blair, favouring competition on quality, rather than price. We know what quality doesn’t look like (Mid Staffs, Maidstone, ten percent of general practices) but very rarely to patients get a seamless service throughout the NHS with no unnecessary visits, waits, harm or duplication. Lansely’s mantra is ‘no decision about me, without me’ but most patients are clueless about the reforms, have no representation in the GP consortia and are not being consulted about how to improve services or how an increasingly tight budget should be spent.
In the event, the BMA bottled it, deciding not to oppose the Health Bill just to shout grumpily at it. The BMA will never strike, even if the members were brave enough to call for it, but Lansley knows that without the engagement, support and leadership of doctors, his reforms are doomed. The Health Bill is ridiculously complicated and policy is being made up on the hoof, but there is no escaping the cuts in services that the financial crisis has precipitated. GPs in consortia are not keen to put their heads above the parapet to announce that local services will have to merge or close simply because there is no money, and are hoping Primary Care Trust managers will do the dirty work before they go under.
If the Government sticks to its budget, closures are inevitable in the next five years, particularly of hospital services. The only way of avoiding harm to patients is for the rest of the NHS to collaborate to try to redistribute the workload. But the market system won’t allow this. Foundation Trust hospitals have been cut free from Whitehall and some are sitting on substantial profits that they aren’t sharing with their impoverished neighbours. Hospitals with huge PFI debts simply aren’t viable in the long term. Patients want the cosy certainty of good quality healthcare on the doorstep when they need it, but unless there is huge investment in community services this isn’t going to happen. The NHS was founded on a pooled-risk principle, where the healthy and rich subsidise the unlucky and feckless. If it focuses on collaboration and prevention, it might just survive as a patchy provider for all. If it allows Foundation Trusts, private companies and GP consortia to chase and keep profits, then you wouldn’t want to be unlucky or feckless.