The early institution building of a new NHS
The NHS is dying, pretty well exactly as I said it would some two years ago now:
Some scandals may emerge in time over ‘backhanders’ paid by the private hospitals to the private commissioners, and in some circumstances it will turn out that the people doing the commissioning are simply commissioning themselves in another name – the whole inefficiency of which the provider-purchaser split was supposed to stop – but it will all be a bit esoteric and complicated for people to understand, and there won’t be much of a fuss.
In fairly short order, we may get these new commissioners creating two tiers of provision from within GP surgeries, with one level of care for those not paying, and those who just happen to have signed the relevant insurance policy forms, which just happen to be in the GP surgery.
Insurance-based healthcare, and the exclusions that this brings, will come not through a government announcement, but by the surgery backdoor……
The consortia [now called CCGs] will end up being led by two or three ‘movers and shakers’ in each area, whose job will be simply to negotiate a decent deal for their colleagues and let the private commissioners get on with the rest. There will be no revolt in primary care, and in secondary care no-one will actually notice till it’s too late.
Two years on, it’s being more widely recognised that, as of 1st April, the NHS privatisation will being quietly but in earnest, as the section 75 regulations kick into gear, Clinical Commissioning Groups with often overwhelming direct financial interests in private providers put services out to the market, public provision withers on the vine or simply goes bust, and private insurance arrangements start to become the norm, initially for (the more profitable) elective healthcare, and then for the rest. As Lucy Reynolds from the London School for Hygiene & Tropical Medicine rightly notes, what comes next in this wildly ‘imperfect’ market is market abuse and health cost inflation. This inflation around the ‘cherry-picked’ services, Lucy might also have noted, will lead to the stripping of resources from the less profitable services – no health budget ring-fencing will protect that.
So what is to be done? By 2015, if and when Labour regains power, the promise of a repeal of the Health & Social Care Act (and the accompanying Section 75 regulations) may be a welcome statement of principle, but it will not significantly change the way in which services have already been privatised, seemingly irrevocably. In many cases, there simply won’t be the public services to transfer them back to, and the incoming government is likely to consider the full-scale implementation of NHS II a little too much of a fiscal challenge, even if the recreation of the cumbersome institutions of 1948 were desirable.*
What Labour can do, though – and needs to start thinking through now – is to tackle the local institutional architecture, in a way which creates the platform both for the establishment of local democratic control of both the type and quality of provision. If it gets this right, this might actually lead, in the medium term, to a better health service than we currently enjoy - as I’ve noted before, it does not become Labour to gloss over the very clear health and social care failings caused by the managerialist ideology that has held sway for the last thirty years.
More specifically in terms of local institutions, the Labour government-in-waiting should first consider retaining the Clinical Commissioning Groups. but diluting the power of GP practices within them by making theirs a minority voting position, through the introduction of members of Foundation Trust governing councils (increasingly focused on quality standards if the Francis Inquiry recommendations are carried through) along with elected councillor representation in keeping with Councils’ new public health function. The immediate impact of this is likely to be presumption against private sector provision where other options still exist (they won’t in many places).
Second, the Labour government in waiting should commit to ensuring that these new-style CCGs adhere both to the letter and spirit of the Public Service (Social Value) Act 2012 under which all CCGs (and the NHS Commissioning Board), have a duty to consider:
(a) how what is proposed to be procured might improve the economic, social and environmental well-being of the relevant area, and
(b) how, in conducting the process of procurement, it might act with a view to securing that improvement.
(Oddly, this is Tory legislation, aimed primarily at breaking the perceived monopoly power of local authorities, but can be used to the same effect against private sector dominance in healthcare provision. That will really piss off the Tories….)
These two relatively simply steps will set the direction of travel back against wholesale privatisation, although of course attempts to terminate contracts are likely to result in lengthy and quite likely unsuccessful legal battles, so early progress is likely to be quite slow.
Nevertheless, institutional change at local level by government, especially if accompanied by moves within the Labour party and the broader movement to re-energise Trade Councils, in a move away from the vapid Tory ‘consumer localism’ and towards a quality-oriented ’worker localism’**, could provide early impetus for the creation of a properly socialist health and social care system – a system fit for the 21st century (whether or not this is tax-based or progressive social insurance based doesn’t really matter as long as it provides for equitable provision) , with private operators increasingly steadily cleared out in favour not just of direct NHS Trust delivery, but also a new surge of worker co-operatives (although charities and social enterprises may also play a valid part).
* It is always worth remembering, in the context of the fetishisation of the 1948-style NHS, that until very late in the day a radically different – and I would argue preferable – NHS structure was being argued for. This was a much more decentralised and locally accountable system, rather than the monolith we grew to love despite it tendencies to managerialism (and I would argue that this is why service standards have declined in the NHS faster than in local authorities, say). See Rudolf Klein’s seminal The Politics of the NHS for more (the later edition is called The New Politics of the NHS but the early chapters are the same).
** This is not to argue for the introduction/retention of localised terms and conditions. Trade unions should of course be encouraged to negotiate at national level, and a properly brave/strategic Labour government would use the need to ‘renationalise’ the NHS, and to invest quality in the hands of its staff (as opposed to its bosses) as a rationale for the relatively painless (in terms of reactionary public opinion) repeal of restrictive trade union legislation. Frankly, I’m not holding my breath on this one.