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December 22, 2014

Private Eye Issue 1380
Filed under: Private Eye — Dr. Phil @ 11:48 am

Choice Words

When MD debated the Health and Social Care Act with its creator, Andrew Lansley, on BBC 1’s Question time 3 years ago, my main concern was its focus on competition (86 mentions) over collaboration (0). The most competitive, consumerist health service in the world (America) is also the most expensive, unfair and wasteful. It spends 16.9% of its GDP on health, compared to the UK’s 9.27%, and yet average life expectancy is lower. The UK also spends considerably less than Holland (11.77%), France (11.61%), Denmark (10.98%) and Canada (10.93%). No wonder it’s struggling.

Competition and choice require spare capacity which the NHS was never going to be able to provide with an ageing population and a £30 billion black hole in its finances, and it’s not easy to shop around and travel for treatment when you’re ill. Yet when the Bill was enacted, a ‘factsheet’ was produced by the DH claiming ‘choice and competition are a powerful means for the NHS to deliver high quality services for patients, and value for money for taxpayers’ and ‘there is emerging evidence of the benefits of competition in the NHS. Where there is competition and choice, it leads to better outcomes.’ Strange then that the Five Year Forward View written by NHS England boss Simon Stevens last month doesn’t mention the word competition once.

Even more surprising, in a recent interview with the Health Service Journal, Lansley’s successor Jeremy Hunt admitted patient choice ‘was not the main driver of performance improvement, contrary to the emphasis placed on it by various governments and senior NHS leaders since the early 2000s… there are natural monopolies in healthcare, where patient choice is never going to drive change.’ He also admitted ‘the market will ever be able to deliver in the top priority area of integrated care…’, ‘choice is ‘particularly irrelevant in emergency care’ and market forces’ would not create good integrated community care – one of the service’s main priorities.’

This apparent about-turn in ideology coincided with an excellent report by the New Economics Foundation called ‘The Wrong Medicine’, which summarises the overwhelming weight of evidence that competitive markets are bad for healthcare. Pointless competitive tendering is risking the ruin of some excellent, well established sexual health services. And lobbying by Spinwatch and 38 Degrees has finally managed to get NHS England to publish where its money goes, and has revealed how expensive it is to run a hugely complex health market that doesn’t work, with vast sums still spent on management consultancy and legal fees. The NHS has now hit a wall financially, with foundation trusts posting their first ever overall deficit. To balance the books, services are being widely rationed and restricted, and patients are being prevented from moving around the NHS to the hospital of their choice. So for Hunt to promote choice now would have been politically disastrous.

The Steven’s plan may now be the only game in town, but his belief that the NHS can somehow conjour up another £22 billion of savings in the face of an increasingly demanding, sicker, older population beggars belief. What is clear is that, once the election is out of the way, the NHS is going to be ‘transformed’ (not reorganised or restructured) like never before. GPs can’t cope with demand and half of GP practices have vacancies, emergency departments are stuffed to the gills and critically ill patients are dying when they could be saved. So Stevens has come up with Multispecialty Community Providers (MCPs), Primary and Acute Care Systems (PACS) and a redesign of urgent and emergency care. It looks faintly plausible on 40 pages of A4, enough to encourage George Osborne to pretend to put £2 billion more into the NHS (but only £1billion extra). But it will require a massive effort of collaboration across the NHS where organizations stop fighting over their individual pots of money. Steven’s first challenge – to get the few Foundation Trusts that are still sitting on profits – to share them with the rest of the NHS is facing stiff opposition. Managers are still being blamed and sacked for missing their targets, so why give up your nest egg?