A Guide to The NHS Reforms
A short history of the NHS
The list that follows focuses on the political reorganisation of healthcare in the NHS,
1948 Labour overcomes opposition from doctors' leaders to establish the NHS, effectively nationalising healthcare and providing treatment free at the point of use, financed by central taxation.
1962 Conservative health secretary Enoch Powell launches a grandiose hospital building plan with the ultimately thwarted ambition of placing a general hospital in every community. The Hospital Plan, put forward by Enoch Powell, set out a 10-year vision for hospital building. Every population of 125,000 was to get a hospital - or district general hospital as they become known.
1974 A large-scale administrative reorganisation of the NHS in England planned by the Tories is implemented by an incoming Labour government, placing all health services into regional and area health authorities.
1987 Conservative prime minister Margaret Thatcher commissions a review of the NHS, amid concerns over growing financial pressures. This leads to the creation of the "internal market" in 1991 under the auspices of the then health secretary Ken Clarke. The market splits health authorities (which commission care for their local population) from hospital trusts (which compete to provide care). GP fundholding, which gives some family doctors budgets to buy care on their patients' behalf, is introduced.
1990 - NHS and Community Care Act The legislation introduces what became known as the NHS internal market with health authorities given their own budgets to buy care for local populations from hospitals.
1997 New Labour under Tony Blair is elected with a promise to scrap the internal market and GP fundholding, and to replace competition with collaboration.
2000 After the NHS staggers under the pressures of a winter hospital crisis, Labour responds with an ambitious "NHS plan" and massively increases investment. It re-adopts the principles of competition and markets, expands the PFI, or private finance initiative, to build scores of hospitals through private enterprise, and hires firms to provide some clinical services, while drawing up a vast array of performance targets and national guidelines in an attempt to create uniform standards of care. Primary care trusts are created to purchase healthcare on behalf of GPs.
2006 - Patients were given the choice of four or five hospitals, ending the long-held tradition of going where a GPs decides. The scheme has now been extended to include all hospitals in England. But the approach not adopted elsewhere in the UK.
2010 Prior to the election, the Conservatives promise to avoid "massive structural reorganisation", but the health secretary Andrew Lansley has drawn up radical plans which will give spending power back to GPs, sideline primary care trusts, give the private sector a bigger role, and dismantle much of the architecture of regulation and targets introduced by Labour.
Commentators call the proposed changes the biggest reorganisation of the NHS for decades. More properly they should say, the biggest reorganisation since the NHS was set up in the shape of the Health and Social Care Bill.
The NHS: The Blair Years 1997-2007
Blair presided over the darkest days of the NHS, none murkier than the insidious growth of management numbers. Between 1997 and 2007 the number of managers in the NHS grew from 20,000 to 40,000, during the same period the number of available hospital beds fell by 70,000. Patricia Hewitt, Health Secretary claimed that "fewer beds are a sign of success - not failure" - nothing to do with the frontline service cuts that she insisted on. 20,000 healthcare jobs were lost, recruitment was put on hold and training budgets slashed.
During the same period, spending on management consultants rose to £600 million a year. That works out at £15,000 of consultancy for each NHS manager.
Quite naturally in 2003 NHS managers required an outside consultant to set up its National IT Programme. The chosen man was from Deloitte on a salary of £200k a year. He was confident that the system would be installed on time and to budget and would meet all expectations. By 2007 the cost of the system rose from £2.3 billion to £12 billion, the 3 year completion deadline came and went, no expectations were met but hospitals have seen a large amount of disruption. In 2007 the man from Deloitte left the building muttering that he knew all along that this was going to be a tricky project to complete... in fact he actually said in 2003 that the project didn't terrify him, it was just an ordinary mid-size project.
And quite naturally, the Blair government hired an expensive firm of PR consultants to deflect any criticism of the failed IT system.
Mismanagement and ineptitude signify the Blair NHS years but so does woeful neglect of patient care. The annual number of unnecessary deaths resulting from hospital-acquired diseases such as MRSA and C-Diff amount to criminal neglect. Rates of MRSA alone doubled over the period between 1997-2004 to over 7000 a year. Health Secretary at the time John Read pledged to reduce this rate by 2008 by a half, i.e. back to the level of 1997? However, fate took at hand to help him out, C-Diff came along and killed off people who would otherwise contracted MRSA, so naturally Mr Read chalked that one as a success in the fight against MRSA.
The total annual figure for hospital-acquired infections is around 300,000; little wonder that 55% of GPs surveyed have private health insurance - still they can afford it, following the ridiculous pay rise that New Labour gifted them to facilitate its market facing reforms.
In Sum: All New Labour's spending on the NHS, around £300 billion in real terms, did little to improve the inefficiency, waste, mismanagement and neglect that characterises much of the health system.
The ConDem Reforms
The Health and Social Care Bill, currently (April 2011) on hold mid-way through its passage through Parliament, is set to radically alter the way the NHS in England operates.
Introduction
This Bill needs to be set in the context of the Coalition Governments Cuts agenda. They have pledged to increase spending by 4% on the NHS over the life of this parliament. However, there seems to be a bit of slight of hand occurring. Over the same period the NHS is expected to find £20bn in 'efficiency savings'.
This drive for efficiency is already begun - a diktat has gone out telling hopitals to put the breaks on non-essential surgery, i.e. unless your condition is life threatening, you'll have to live a lot longer in pain. Just how making people in agony wait longer for an operation adds up to an efficiency is beyond understanding but it's happening now. (See side note, Delaying Tactics). The point here is that The Health and Social Care Bill will introduce massive change in the midst of this efficiency drive.
The low productivity argument
Beyond the cuts agenda, the Government also claims that the NHS must become more productive and claims that its Health Reforms will deliver this higher productivity. The Lancet (Feb 2012) says that the Government's statistics are faulty and real picture is one of rising productivity in health.
The Current State of the NHS
The infrastructure: one million staff, 200 major hospitals, 8000 GP surgeries, being run by 151 primary care trusts (PCTs) and 10 strategic health authorities (SHAs).
80% of the budget is held by local managers working for the PCTs.
Private sector provision: currently, the private sector is supplying treatment for 30,000 citizens a month, carrying out hip and knee replacement and eye surgery.
The Proposed Changes
GPs will be put in control of much of the NHS budget. From 2013, they will take over planning and buying local services.
These changes will cost an estimated £1.5 billion, and PCTs and SHAs will be scrapped. Note: a new National Board will be put in place to fund 250 plus Clinical Commission Groups. Where these groups can't be set up initially, funding will go directly to GPs and dentists from the National Board.
Also, private hospitals will be able to compete with NHS hospitals for customers.
The Cost of the changes
The cost of the programme is £1.4bn.
Most of that will come in the next two years as more than 20,000 management and administration staff are made redundant from health authorities, PCTs and the Department of Health
The Government View
The Government says these changes are necessary to meet present day demands, factors such as the ageing population, cost of new drugs and the rise in obesity.
The hope is that the service will be more responsive to the needs of patients with the GPs in charge. In particular, it is hoped that they will help set up more services in the community which tends to be cheaper than seeing patients in hospital.
And, of course, opening the door to the private sector will drive up standards - it may also lead to hospital closures. But allay those fears, they have also pledged to spare rural A&E provision - if you believe that you're on the wrong planet.
The case against the changes
Reigned against the changes is just about everyone who knows anything about the NHS; The House of Commons' Health Committee, health managers, the British Medical Association, Royal College of Nursing and Unison. The Royal College of GPs have suggested doctors could have just been given a more prominent role on the boards of PCTs.
In Sum: those against the changes argue that they will destabalise the service, will lead to increased privatization, lead to closures and most damning - much of the change is unnecessary. It's worth noting that under the proposed new arrangements the existing cap on private patient treatment in hospitals will be removed and that the Secretary of State will effectively be washing his hands of any responsibility for health care in England.
This Government has had more than a few shilly-shallying moments and we expect this to be a great moment - when the vested interests railed against are so tough. However, lined up on the other side are the deep pockets of the global health care industry. They see in the NHS a golden opportunity to make a killing. They are using a network of pro-market and Think Tank lobbying groups to push through the reforms. (Do visit SpinWatch for all the complicated details of how 'deep democracy' really works.)
The third reading of the Bill will occur on Tuesday 6th September, it will then pass to the House of Lords in October.
Update: Feb 2012 - Thus far the Lords have found most aspects of the Health Reforms wanting. The Government insists that the Reforms will go ahead.