openNHS

National Health Service Megatrends

The National Health Service Megatrends

Thanks to the work of the late Sterling Professor of Medicine and Epidemiology Alvan R. Feinstein , the likely "evolutionary pathway" and the end result of the "metamorphosis" of the National Health Service has been laid before us. One only has to look across the Atlantic to "see the future" in plain sight.

It is now up to us, clinicians and patients alike, to digest these works and decide if this is the future of medicine that we want for ourselves and our future generations.

The silent march of "Internal" Markets

As with all metamorphic changes in nature, it marches forth hidden within a cocoon. For the NHS, the cocoon is "Change", "Choice", "Private Finance Initiative (PFI) ", "Independent Sector Treatment Centres (ISTC)" and "Modernisation" under Labour.

Under the new Conservative/Liberal Democrats government, the cocoon is "Liberation of the NHS", "GP Commissioning " and "private-sector-assisted commissioning".

By removing all of the Primary Care Trusts and Strategic Health Authorities, the way is now open for the private sector to be "involved" in the commissioning of health care for all in England. Few GPs have formal training for such a huge task and it is inconceivable that many GP will be able to find additional time in their already full schedules to take on this additional burden on their own.

Hence the creation of "GP Consortias", another "ISTC-like" entity for all intent and purposes, where the private commissioners provide the commissioning service using public funds entrusted to the GPs.

Point 23 in the executive summary of the "Liberating the NHS: Commissioning for Patients - A Consultation on Proposals" white paper states that:

"Consortia will have the freedom to use resources in ways that achieve the best and most cost-efficient outcomes for patients. At the same time, the economic regulators and the NHS Commissioning Board will ensure transparency and fairness in spending decisions and promote competition, for instance by ensuring wherever possible that any willing provider has an equal opportunity to provide services."

The focus on "freedom to use resources", "willing providers" and "equal opportunity" suggests that any private health care provider will be given "equal opportunity" to compete with "traditional" NHS providers under the "any willing provider" banner.

This is simply another step forward in the general trend already established by the previous Labour government under their Patient Choice initiative, which promoted the use of private health care providers in the form of Independent Sector Treatment Centres in order to "improve patient outcomes". This focus on "Patient Choice" is also carried forward in the current "Liberating the NHS" push.

The NHS faces additional challenges under the newly-elected Conservative/Liberal government "financial prudence" banner. This really is unnecessary as the NHS is the most efficient national health care provider amongst 7 developed nations in the latest Commonwealth Fund report, published in June 2010.

Despite the billions of pounds poured into the commercially inclusive and open source exclusive (even openEHR was side-lined until recent years) NPfIT project, there are trusts that are encountering difficulties in maintaining clinical services. With the minimum of staff and funding (in order to be "efficient"), they are kept going by the good-will and commitment of many of its' staff, volunteers and other NHS affiliated charitable organisations in putting the patients interest first above all else.

To further restrict funds centrally and increase workload would leave these trusts with no alternative other than to source for even more private funds, and "compete" with each other for private funds, GP fundholding and patients.

Then again, the former is already enshrined as part of the "Foundation Trust" manifesto established under Labour rule, where NHS Foundation Trust Hospitals will no longer be accountable to the Secretary of State, can have access to private funding and keep any surplus "income" generated.

In principle, there is no difference in the above to what Margaret Thatcher had in mind in 1991, the same principles that Tony Blair pledged to reverse in 1997.

The metamorphosis of the National Health Service, driven by "internal market forces", looks set to continue and complete its 20 year old journey, regardless of which political party is in office.

Recent documents released from the National Archives on the 28th December 2012 suggests that the plans for privatisation of the NHS were drawn up by Thatcher's Tory cabinet by 1982, extending the journey to over 30 years, right up to the passing of the NHS Reform Bill in 2012 (also known as "Health and Social Care Act 2012") .

First, create a market for internal services. Then create a market for Foundation Trusts with GP Commissioning. Then employ private commissioners to manage these funds, with the ability and freedom to purchase services from private healthcare providers in an "open" and "competitive" market.

This would then naturally create a market for clinical staff. (The flexibility in setting pay and benefits for clinical staff are already part of the manifesto for Foundation Trusts.)

"Better" doctors and nurses would then naturally gravitate towards "better" health care providers whom can pay them "better" salaries.

And then finally, private health care insurance will naturally follow to fill in the gap, and pay for the additional "premium'", above and beyond the "national budget and funding", which will naturally arise as patients start to choose these "better" health care providers.

At this point, the NHS would be truly "liberated", with further progress and development to be led and paid for by the private sector.

There will be no need for any withdrawal of national funding for healthcare for the health insurance industry to take root and establish itself in this setting.

As such, it would seem that we are at the most, 2 steps away from the formation of a full-fledged private healthcare system in England.

Private Finance Initiative, Independent Sector Treatment Providers and the NHS

Furthermore, physically and structurally, the National Health Service is already fast disappearing. All new hospitals built under the Private Finance Initiative (initiated in 1990s under the Conservatives and continued by the Labour government) belongs to private consortiums.

The buildings and all supporting ancillary services are then leased back to the government under long term contracts, averaging 30 years or so.

Hence, we have reach a stage where hospital buildings and supporting services are privately owned and run, the hospital Trusts independent of the government, able to acquire private investments and keep any surplus funds generated, staffed by public doctors and nurses, and patients receiving treatment paid from the public purse.

Just replace the doctors and nurses with privately funded staff and it may as well be one of the Independent Sector Treatment Centres (ISTC).

One may even argue that it would be better for Private Healthcare Consortiums to operate under a Foundation Trust housed in a PFI Hospital scenario, as this would mean that operational costs are guaranteed to be paid with public funds for the next 30 years, the hospital would be staffed with NHS doctors and nurses and there would be a guaranteed stream of customers, in the form of NHS patients.

They can then arrange for ISTC-like bulk contracts of non-emergency care with in-built profit margins, where the quota for the service is pre-arranged and paid up regardless of whether the numbers are achieved or not at the end of the contracted term.

Minimum risks. Maximum profits. With complimentary use of the well-established NHS "brand name" and logo.

A rose by any other name would smell as sweet...

The difference between "internal markets" and "open markets" lies only in one word. It would seem from the above that the change in this one word is not required for the subtle process of "privatisation by stealth" to be complete.

This process, aptly and ironically, summed up by Tony Blair in 1995, as he addressed John Major:

Is not the effect of government policy on the health service now to pit nurse against nurse, hospital against hospital, and doctor against doctor? The result will be to divide and rule; and the commercialisation, demoralisation and break-up of the health service, when people want to see the National Health Service run as a proper national service for the people.”

Hansard, 27th April 1995, Engagements (HC Deb 27 April 1995 vol 258 cc977-82)

One can only hope that with all good intentions going forward, the single most important principle of providing good health care is not left by the wayside.

The secret of caring for the patient is to care
for the patient

Francis Peabody, 1927

NHS Reform Bill: The Completion of the Privatisation of the NHS (1982 - 2012)

The truth of the matter is that the current NHS Reform Bill (aka Health and Social Care Bill 2012) is not the start of the privatisation of the NHS. It is the end of the process and seeks to make privatisation of the NHS permanent, legal and binding under English law.

Once passed into law, it will signal the end of the 63 years of "British Renaissance", when the health of all British people came first before everything else in the nation.

In these final days of the NHS (the Lords voted on the 20th of March 2012), the following lines will echo through the land in the hearts and minds of the good British people...

"Rage, rage,
Against the dying of the light,
Don't let the NHS go quietly into the night...
"

Do not go gentle into that good night

Do not go gentle into that good night,
Old age should burn and rave at close of day;
Rage, rage against the dying of the light.
Though wise men at their end know dark is right,
Because their words had forked no lightning they
Do not go gentle into that good night.
Good men, the last wave by, crying how bright
Their frail deeds might have danced in a green bay,
Rage, rage against the dying of the light.
Wild men who caught and sang the sun in flight,
And learn, too late, they grieved it on its way,
Do not go gentle into that good night.
Grave men, near death, who see with blinding sight
Blind eyes could blaze like meteors and be gay,
Rage, rage against the dying of the light.
And you, my father, there on the sad height,
Curse, bless me now with your fierce tears, I pray.
Do not go gentle into that good night.
Rage, rage against the dying of the light.


Dylan Thomas (1914–1953)

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Page Updated: 27 May, 2017

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