The tax increases announced yesterday prove one thing: the NHS has a political importance that limits what governments can do to undermine it. I want to talk about the extent to which previous reforms have been limited in their impact, not least because of the role of campaigners.
30 years ago the Thatcher government was launching the internal market system that first allowed major hospitals to “opt out” as “self governing” trusts which were required to compete with each other for contracts.
Larger GP practices were also encouraged to “opt out” by becoming GP Fundholders with budgets for elective care.
The internal market also meant pricing and billing of treatment between trusts. Cash limits were imposed on most primary care. Trusts were encouraged to break from national pay agreements and negotiate local deals.
Oh – and this was also the NHS and Community Care Bill that created today’s nightmares in social care. It pushed long term care for older people out of the NHS where it was free at point of use and into local government, where it is subject to means tested charges and with care homes and home care increasingly fragmented and privatised.
What happened? Huge amounts of bureaucracy was added to the system, huge sums of money wasted or pocketed by fundholding GPs, waiting lists stayed high and went higher: but other than long term care, almost no patient care was privatised. The unions almost everywhere beat back plans for local pay.
Skip forward ten years. New Labour’s 2000 NHS Plan seemed to set course for wholesale privatisation: new hospitals were financed through PFI, targets were set for 15% of all NHS elective work to be done by private providers. Independent Sector Treatment Centres were set up. Corporations began buying their way into GP contracts – Virgin’s GP practices then covered more patients than Centene does today: United Health tried to move in on GP contracts.
From 2005 commissioners were instructed to hive off the community health services they were still mostly running – to any willing provider.
We were so concerned as campaigners we set up Keep Our NHS Public to challenge all forms of privatisation. And the pressure we brought to bear played a role in limiting how far New Labour could go: but we had help, because most corporate GP contracts were not profitable – and collapsed. The Treatment Centres were controversial, much more expensive than NHS operations, and unpopular. Most of the NHS remained firmly in the public sector.
Then came David Cameron’s coalition, which proposed a massive top-down reorganisation to entrench the NHS into a rigid competitive market system requiring local commissioners to put contracts for anything costing more than £600,000 a year out to tender.
Lots of people listening tonight will have been part of the campaigns against the Lansley Bill. It split England’s NHS into 207 Clinical Commissioning Groups, initially with GPs being notionally in control but in fact often run by management consultants.
It empowered Foundation Trusts to make up to half their income from private medicine – and required all NHS Trusts to become foundations.
Ten years ago I wrote the headline Kill Lansley’s Bill – before it kills the NHS. Back then there was a real chance right up to the end that we could kill that Bill if we could just break off the LibDems.
But what actually happened? Bits of the Bill were watered down, sections of the Act simply could not be implemented – not least all trusts becoming foundations. Big privatisation schemes in Cambridgeshire and Shropshire, and the franchising of Hinchingbrooke hospital management to Circle collapsed because they were not profitable.
No foundation trust has even got close to making half their income from private work – although several are trying to do so. Many small scale community contracts were privatised, while most of the larger contracts, especially those involving risk, remained NHS.
The spending on private providers grew – but as a proportion of NHS England spending it has levelled off. Not including GPs and dentists, 18% of NHS clinical spend is with private providers. That’s 18% too much, of course – but much lower than lots of people seem to think.
From 2014 onwards – the year after Lansley – NHS England began looking not to break the NHS into more piecemeal contracts but to bring together specialist services – pathology, imaging, diagnostics and technological support – into profitable framework contracts which are already being awarded without tenders or competition to pre-approved lists of providers.
These same ideas are in the Health and Care Bill – which we oppose for the reasons many people have voiced this evening. I would sum up my concerns this way:
- It does not end or reverse privatisation – or even competitive tendering, but could allow private health companies to sit on ICBs;
- it gives the Secretary of State sweeping new powers – but does not reinstate the duties to promote comprehensive service that were swept away back in 2012.
- The reduced number of ICSs drastically reduces local voice and accountability on cuts and closures for councils communities and constituencies;
- the Bill leaves Foundation Trusts free to ignore local plans – and to maximise private patient income – as some are trying to do.
- It gives no voice on ICBs to patients, or to mental health, or to public health, or to health workers or trade unionists.
- The proposed new payment scheme could lead to a postcode lottery on the level of funding for specific services
- and new powers to deregulate professions could undermine quality and safety of care.
We need to fight against the Bill because of these issues, but also support the effort by opposition parties in parliament to amend the Bill to remove the most damaging bits. Through Health Campaigns Together we have been discussing with the unions and the Labour team how to fight the Bill.
Time is tight. Part 1 of the Bill – including all the sections on ICSs, which have attracted most opposition – will be debated in the Commons for just 2 weeks from next week. There will be no further chance to challenge this part of the Bill until the House of Lords takes up the Bill.
Those of us with Tory MPs and Tory councils need to hold our noses and clench our teeth to write explaining to them, in terms they can understand, why they, too, should urge their colleagues to back amendments on these same questions.
We’ve got plenty of NHS to defend.
Let’s make sure we don’t miss the chance to build the kind of pressure on back bench MPs that can get clauses and proposals dropped or amended – and ensure whatever Bill may be passed in the end does not do the damage we fear.
It’s still our NHS. It’s still vital. Let’s Keep Our NHS Public!
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