How to save the NHS? A key issue in the 2015 General Election run up

The future of the NHS is shaping up to be a key battleground for all three major parties in the run up to the 2015 General Election.

Already the Halifax Tories, Calderdale Labour Party and Calderdale LibDems are staking out their positions on the proposed merger of Calderdale and Huddersfield A&E departments on a single site in Huddersfield.

It’s not clear from the three parties’ statements that any of them are really looking at how to solve the underlying problems that have led to the proposed A&E merger. These include:

  • the tidal wave of backdoor NHS privatisation, triggered by the Coalition government’s 2012 Health and Social Care Act (HSCA), along with heavy NHS spending cuts and staff cuts  (aka efficiency savings)
  • massive Private Finance Initiative debt repayments on Calderdale Royal Hospital
  • sharply rising A&E admissions as a result of Coalition government cuts to social care services

The public’s campaign to keep the NHS public is having some significant successes, like the Save Lewisham Hospital Campaign. But the Coalition government is busy introducing new laws that will make such successes next to impossible.

We have to act now to stop the Coalition government from making these laws:

  • Care Bill aims to allow hospital and A&E closures without public consultation
  • Gagging Bill will prevent organisations like 38 Degress and Trade Unions from campaiging against government policies in year before elections – unless we stop it
  • EU/US Trade Agreement would make health a trade issue, not a way of providing for people’s needs – ask your MP to sign Early Day Motion 793

Beyond these firefighting campaigns, it’s clearly important to take stock of the big picture and figure out realistic, effective political objectives to make sure that our NHS survives and thrives for at least another 60 years.

“It is easy to be so taken up with fire-fighting immediate problems that we overlook the big picture” (Jacky Davis & Raymond Tallis, in NHS SOS – How the NHS Was Betrayed and What You Can Do To Save It, p214)

The big picture and how we can save the NHS

The 2012 HSCA became law without any electoral mandate. How did this happen? Because no political party or  parliamentary institution was willing or able to stop it. Politicians’ vested interests in private healthcare companies were a significant aspect of this failure. The Social Investigations website said private healthcare companies are”

“benefitting from a system that allows our MPS and Lords to vote despite a conflict of interest.  A bill that had no mandate from any party, in a sector that financially links 142 Lords and multiple MPs (ongoing) to companies involved in private healthcare.”

Another key factor was that New Labour had already carried out a range of NHS privatisation reforms and this stifled effective opposition within Parliament.

So where is effective political defence of the NHS – in Calderdale and nationally – going to come from?

What are the options for future NHS policies?

The 2015 general election campaign is not far away;  people who want to keep the NHS public need to be clear about realistic objectives for the next five years.   What can we expect of politicians? How far may it be appropriate (possible) to push them? What direct questions do they need to answer?

Here’s a list that isn’t definitive, but it’s a start.

1. Do nothing;  this would result (inevitably it seems) in unequal provision and access to NHS services, and a “post-code lottery” regarding what services are provided at all in any particular area.   The possibility of charging for some services which currently are free also seems to be a likely one. Apart from the Conservatives, no party seems to favour this.

2. Restore the legal duty of the Secretary of State for Health to provide all NHS services in England.

This legal accountability no longer exists, as a result of the 2012 Health and Social Care Act.

The people who designed the NHS, as part of the 1944 Beveridge Report, recognised that social fairness in health care depended on sharing the risks and costs of care across the whole society – from rich to poor, from healthy to poorly, from urban to rural. Services were integrated so patients couldn’t be denied healthcare, or passed between agencies anxious to save money by avoiding responsibility for patients with expensive health care needs. Everything was paid for out of taxation.

The Secretary of State for Health had a core duty to provide or secure this comprehensive health service. This compelled the Secretary of State to provide health services according to need, and not to leave the provision of health services to market forces and organisations that were not democratically accountable. This duty, which the 2012 Health and Social Care Act repealed, was essential to the NHS.  The Secretary of State for Health could be held to account legally for the services that she or he was responsible for by law.

Restoring this legal duty probably needs to be  a component of more substantial reforms, as considered below.

3. Keep the purchaser/provider split and require existing commissioning bodies to continue to commission services, but only from NHS providers  except in certain specified situations where these may not be available. This is, broadly speaking, the situation before 2013.   Is this the policy that the Labour Party seems to be heading towards?

4. Abolish all CCGs, NHS England, Public Health England, etc., and establish health authorities to commission all services for their populations.

Probably around 80 health authorities in England, as recommended originally for the 1970s NHS reforms, would be responsible for commissioning all services for their populations, under the guidance of professional committees which would include substantial primary care representation (GPs).

Several such advisory bodies, representing smaller geographical areas, could advise a single health authority. These authorities would have sufficient “clout” to deal adequately with large powerful providers. They would commission on the basis outlined in option 3 above. Currently no party appears to be thinking along these lines.

5. Abolish the “purchaser / provider split” – in other words, restore the NHS in England to something like it was before 1990 

In 1990 the Thatcher Government announced that it would separate “commissioners” of health services (the people who planned the health services) from provider organisations. This was called the creation of an “internal market” in the NHS. The commissioners would “contract” specific services from the providers.

It meant that hospitals had to compete with each other for NHS funds. Instead of the previous system of block grants, hospitals were paid on the basis of the numbers of patients they treated.

The Thatcher government also initiated the practice of outsourcing/privatising elements of the NHS, eg hospital cleaning and other support services.

From the mid 1990s the Major Government created “fundholder practices” (general practices with the power and funding to commission services for the populations registered with them).

Abolition of the purchaser/provider split could work in a  scenario where health authorities  (like those indicated in 4 above) might be given responsibility for delivery of all NHS services to their populations, as well as responsibility for planning of these – all subject to overall accountability to the Secretary of State.
This is broadly the current situation in Scotland, where all vestiges of a health market have been eradicated (the First Minister boasts that only in Scotland would Aneurin Bevan find the NHS he knew!).  Only the Green Party appear to favour such a policy direction in England.

6. Whatever else happens, reverse the recent transfer of public health responsibilities to local authorities, in order to reintegrate public health back into the NHS as one of its prime functions, giving back professional independence to public health professionals

The 2012 HSCA transferred most public health functions back to local authorities, causing further fragmentation of the NHS. This can be seen as a handicap both for public health and for the rest of the NHS, which now often lacks public health advice for some planning processes, etc.

Within local authorities, public health departments may no longer be able to provide unbiased scientific opinions if these are contrary to particular political policies being followed by local authorities;  plus, they find it difficult to advocate for healthier policies at other levels (e.g. at EU level).

7. Integrate NHS services with certain local authority social services functions (mainly those serving children, the elderly, and the chronically ill).

If desirable, should this be on the basis of “social services” joining the NHS, as is the situation currently in Northern Ireland (e.g. as an amended option 4 above)? Or should local authorities be given the responsibility to commission (and perhaps to provide?) health services?   Is the Labour Party groping towards some such policy?

8) If health authorities of any kind are to continue to exist, should their members (all or only some?) be directly elected?

Which option/s do people want? And where do the political parties stand?

Option 1 – Do nothing

Almost certainly, everyone who wants to keep the NHS public will reject option 1.

Option 5

Is it realistic to seek to abolish the purchaser / provider split and to create/restore an NHS like it was in England before the 1990s ( and is in NHS Scotland now)? (Option 5)

Options 2 & 3

Is a combination of options 2 and 3 all we should realistically hope for? (Restore responsibility for the NHS to the Secretary of State, and keep the purchaser/provider split, but only commission from NHS providers.)

Option 4

Does option 4 offer any particular attractions? (Re-establish Health Authorities and abolish all all CCGs, NHS England, Public Health England, etc.)

Option 6

Is option 6 an essential requirement, irrespective of the other choices outlined above? (This option is to reverse the recent transfer of public health responsibilities to local authorities, and reintegrate public health back into the NHS as one of its prime functions, giving back professional independence to public health professionals)

Option 7

Does option 7 indicate a desirable direction of travel for the NHS? (This option is to integrate NHS services with certain local authority social services functions;  if desirable, should this be on the basis of “social services” joining the NHS, as is the situation currently in Northern Ireland (e.g. as an amended option 4 above), or should local authorities be given the responsibility to commission (and perhaps to provide?) health services?

If we like option 8, (elected health authorities) how should it be applied to with any of our other favoured options?

Are there other options that aren’t included here?

There is a lot to discuss! And each political party needs to clearly say where they stand.

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