Dr Evan Harris fisks: What is really at stake on the health reforms

On 8th April Norman wrote an interesting article here entitled “The NHS: safe in our hands”. That article is a good basis on which to discuss a few of the problems with the bill and the Government’s approach so far.

We should be clear that Norman Lamb is one of the good guys, who spotted earlier than most the problems with the White Paper and the Bill, and has been very clear that it requires radical surgery. He has also been particularly concerned, and this week expressed this publicly, that the pace of change is financially (and consequently clinically and politically) far too risky.

In his introduction Norman highlighted one key quality of the NHS “Treatment free, when you need it, not when you can afford it. That’s an idea that must never be undermined.

All good stuff, but a treatment is not free when the NHS does not provide it because it is not deemed cost-effective enough to be made available on the NHS. This is rationing and there is nothing wrong with that as long as it is done rationally and that politicians are honest enough to explain to the public that effective but expensive treatments can only become available on the NHS when there are increases in real terms spending. I hope that the Lib Dems, when economic circumstances allow, will always give the public the option of voting for more NHS spending through fair taxation.

Under Labour the NHS became bloated and unaccountable, with more managers than nurses.

The NHS has always been pretty unaccountable and the Health Bill currently plans to make it even less accountable, by reducing scrutiny of local authorities over commissioning and reducing the ultimate duties on the Health Secretary.

By “bloated” does this mean the NHS is over-managed or too big? Are its management costs higher or lower than equivalent health services? All we know is that don’t know as the Health Select Committee concluded last year at paragraphs 33-37 of its report on commissioning. There are suggestions that NHS management costs are increased further by introducing more market transactions.

More managers than nurses?

There are 400,000 nurses. There are patently fewer managers than that! About 40,000 in fact. I presume there is some Government propaganda circulating, rather like this nonsense which can still be found on the official Lib Dem website, which has misinterpreted a report that the percentage rate of increase in the number of managers under Labour was higher than that for nurses. Perhaps this misinterpretation is literally or psychologically cut and pasted into articles as was the infamous “UK as twice the rate of heart attack deaths for patients than France” fiction, which I am pleased to see has been put out of statistical misery?

Bureaucracy must go and patients must get more control. As Nick said in his conference speech in Sheffield, ‘We have campaigned for years for an NHS that gives more power to professionals and to patients.’

The current plans give more power to a sub-group of sub-group of a sub-group of health care professionals. The entrepreneurial few among the GPs who are a subsection of doctors who in turn are a minority of health care professionals. There is no mechanism by which a patient can influence commissioning decisions unless he happens to bump into to the full-time manager, who used to be her GP, at the supermarket and persuades him to commission service X from Y not Z. Compare that to the ability of locally elected councillors or health board members who can be elected on a platform of service change. Anyway, I venture to suggest that if we want the NHS to be a “wellness” service not a sickness service, with more preventive medicine, then those who wish to stay healthy should have as much influence as those already ill. That means the public as whole having a say not just a selected group of them, called patients.

This whole debate on “power to professionals” is fascinating for me a former Health Spokesman. When I used to oppose the politically-based targets (introduced by Alan Milburn and John Reid) on the basis that they distorted clinical priorities and prevented doctors form providing the most appropriate service for their patents, I was accused by David Laws among others of promoting “producer interests”, (and he is still saying it) perhaps especially because I was a doctor myself. I didn’t think that was true or fair (I was alone in opposing the new GP contract at the time as a bad deal for patients). So it is a curious irony to see the Orange book brigade now defending reforms which actually boast about promoting the interests of the producer professionals.

“And change is needed, too, because we must keep up with an ageing population and rising numbers of people with long term conditions like diabetes and Alzheimer’s, and we need to find the money for new treatments and new technologies so people continue to get the world-class care the NHS is known for.”

Change is needed? No. Positive change is needed. The mantra of reform and its justification is only rational if there is both a logical basis why the reforms would deliver positive change, and some evidence from elsewhere, or from pilots here, to back it up. Neither of those apply to these health reforms. No modern day engineer or mainstream clinician would apply something to their entire practice let alone that of the rest of their colleagues for based on dogma or blind faith.

“Paul Burstow has been working tirelessly to ensure that, for the first time, local government will have a real role in our NHS, holding GP consortia to account”

I am sure that that is what Paul would have wanted but its not there in the bill. There is hardly a role for local authorities to be able to scrutinise, let alone challenge, let alone force change to specific commissioning decisions which – until our intervention – were due to be made in secret. The Health and Well-being boards are currently designed to have a minimum of one (yes one!) councillor on and be responsible for a needs assessment and for strategic oversight of commissioning. If the HWB is important then make it a majority councillor body.

Local authorities “taking on responsibility for public health”

Yes, but if public health is detached from commissioning (and it is currently close bound in PCTs) then the role of public health is seriously diminished. That is just one reason (another being integration of health and social care which as Norman says is essential) why co-terminosity of local authorities with commissioning bodies is essential.

Norman quotes Nick saying at Conference of the NHS “World-class health care for all. Publicly funded. Free. Centred on patients, not profit. So yes to health reforms. But no – always no – to the privatisation of health.”

That sentence could have done with a “comprehensive” at the beginning because the bill in its current form proposes comprehensive cover only to those on GP lists, and that is why our motion called for geographically-based commissioning and geographically-based weighted funding allocations.

It is huge benefit for us to have Norman Lamb in the position he holds because he understands Lib Dem policy and can see the huge risks to us of being lashed to the mast of Tory NHS policy. I also think he can see what lies behind these reforms – that they can be used as a staging post for a new system delivered by a future Tory or New Labour Government where Foundation Trusts (ie all hospitals) are sold off and the Commissioning Consortia become Continental-style social insurers. The Liberal Democrats have called this out and we must stop it.

Evan Harris was Lib Dem Shadow Health Secretary 2001-2003 and is a vice-chair of the Federal Policy Committee. You can find him on twitter here.

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23 Comments

  • Evan – I take it you wouldn’t have voted for the bill twice then?

  • @Ben 11.34

    As I have said elsewhere and before, when Government MPs oppose things that are in a bill they do not vote against it at 2nd reading or expect to see changes in Public Bill Committee but vote for specific amendments at Report Stage (and Consideration of Lords amendments stage) and if not satisfied should vote against at the subsequent 3rd reading. That is what Labour rebels did on tuition fees, top-up fees, foundation hospitals, academies and lots of immigration bills 1997-2010.

    Having said that, should more LIb Dems have identified all the problems with the bill at an earlier stage? Yes

    and

    Have the Lib Dems now called for better mechanisms to prevent this happening again?
    Yes

  • “All good stuff, but a treatment is not free when the NHS does not provide it because it is not deemed cost-effective enough to be made available on the NHS. This is rationing and there is nothing wrong with that as long as it is done rationally and that politicians are honest enough to explain to the public that effective but expensive treatments can only become available on the NHS when there are increases in real terms spending.”

    Nail, head hit. Partially – which I’ll come to. For far too long the NHS has been a sacred cow that can never be criticised, and politicias of all stripes have connived to dupe the public into thinking that they will always be able to have any treatment at all times when, patently, they can’t. Rationing exists; rationing has existed; and no politician form any party has been straight enough to stand up and say how it is, and that this will always be the case.

    “when there are increases in real terms spending”

    Wrong. That is one way of releasing more money for patient care; there are two others. One of those is to reprioritise existing spending, and the other (and none of these are exclusive) is to spend existing money more efficiently.

    Now, Dr Harris, put your hand on your heart and tell me that the NHS is run as efficiently as it can be and that there is no waste in the current set up.

  • @Evan

    Thanks for the clarification to what was a mischevious, but worthwhile question, to those of us that are uninitiated with the intricacies of the UK’s somewhat arcane parliamentary procedures.

    -Ben

  • Bill le Breton 14th Apr '11 - 12:55pm

    Back in 1948 George Orwell taught us to resist Government propaganda through deconstructing ‘double speak’. The naming of the draft Health White Paper “Equity and excellence: Liberating the NHS” should have made it obvious to every Lib Dem in Whitehall, (Whitehall I say, not Westminster for good reason). A translation of the resulting White paper and Bill as “Inequity and Expediency: Privatising the NHS” would seem obvious. Calling it a ‘modernization’ of the Health Service with its Blairist accent should have further warned them that here was neo-liberalism dressed as liberalism. They should have strangled it at birth.
    Mark Pack at https://www.libdemvoice.org/reinventing-the-state-22494.html gives a view of how a Community Politics approach would have been diametrically opposed to that outlined in this bill.
    It is because those with leadership responsibilities and positions believe that the way to increase ‘people power’ is through a more efficient market and a ‘smaller’ state, rather than by increasing people’s ability to take and use power either directly or through elected and accountable representatives (ie a more democratic state) that the Party is now firmly associated with NHS cuts and privatizations as well as a litany of policies diametrically opposed to those that the Party campaigned on 12 months ago and which were clearly laid out in our manifesto.
    They didn’t strangle it then and they won’t strangle is now, Evan. The pause is another Orwellian fiction taking them beyond the inconvenience of the elections. The fight will be in Westminster and our MPs will be counted, be they members of the Government or not.

  • Dr Harris’s defeat at the last election was a sad loss to our parliamentary party. We need far more people with his insight and intelligence in order to dissect, expose and defeat the sheer stupidity of some Conservative-led policy initiatives like this.

  • Bill Le B “Back in 1948 George Orwell taught us to … deconstruct … ‘double speak’. ”

    Indeed he did. But Orwell cuts both ways, and that includes using emotive and ill-defined nonsense such as this:

    “A translation of the resulting White paper and Bill as “Inequity and Expediency: Privatising the NHS” would seem obvious.”

    Well its not obvious to me Bill. What exactly do you mean by “privatising the NHS”? That private companies should not be allowed to make a profit out of providing treatment free at the point of use?

    That will discount the companies that built the hospitals. All will have to be built by state employees now. And all those ecompanies that supplied fixtures and fittings. And what about the drug companies? Nationalise them all. And, finally, our dear old GPs, all of whom are members of private partnerships. We’d better nationalise them too as they’re all currently nasty private businesses cynically milking a profit out of sick people.

    At least Evan Harris makes an attempt at engaging with the effects of the bill rather than talking in rabble-rousing platitudes.

  • Tony Greaves 14th Apr '11 - 2:15pm

    The last posting is silly nonsense. The NHS is not a building company. It has to contract with building companies to build hospitals. Equally it has to contract with bandage suppliers to get in bandages. And so on.

    The question is whether the core business of providing health services should be carried out for profit.

    At the margins, it is possible to contract with specialist suppliers of health services and some of those may be for-profit companies, without compromising the basic principle (though each case has to be looked at very carefully to see whether there is indeed overall an advantage). But the commissioning body and the core operation is not for profit, or should not be. And the bulk of services should not be provided for profit.

    As for arcane parliamentary procedures, don’t forget that this Bill (if it survives that long) has still to come to their Lordship’s House.

    Tony Greaves

  • Tony Greaves – are you trying to say GPs are not NHS core business? Because they are all private health providers making a profit.

  • @Tabman

    You do raise a good point, why on earth is anyone considering giving profit seeking private contractors (which is what GP’s are under the terms of their obscene contract) the keys to the candy shop, especially with shockingly little in the way of public oversight or control (and no sticking one or two councillors on-board won’t fix that)

    Before anyone says well GP’s will have the best interests of the patient at heart, the furore about opening hours when they conned Labour into giving them a massive wage rise for working less hours and removing the out of hours provision kind of puts pay to that.

  • Bill le Breton 14th Apr '11 - 3:51pm

    Tabman, many thousands of former NHS employees have been transferred under Labour into PCTs. These are now being transferred to institutions with Foundation status. This entails their second TUPE which means that they lose all their rights gained under their first employment and protected under their second. Why is this so?
    Evan is right to worry that a future single party Government of either Conservative or Labour colours could sell these Foundations arguing that as a provider at the point of need it doesn’t matter whether the supplier is private, public or voluntary.
    Actually it does matter. There are huge gains to patients, the community of the well, future patients and employees from having a ‘public service’ providing a full range of health services.
    Health and profit do not fit well together. Not many years ago I needed a particular test. The NHS waiting time was six months – fine by me. But my PCT without bothering to ask me decided they would engage a private service and I received an appointment at a local private hospital … it was for 10.15 … 10.15pm! When I arrived I was tested by someone who had conducted a full list for the NHS during the day and was doing this for his back pocket into the night! The so-called service was being organized by a former NHS manager who had just that week left the NHS and knew the operator and bid for the work to the PCT (using insider knowledge).
    When I next saw my consultant and asked about the results he told me they were useless – the wrong test had been conducted. Late night performance, obviously. I asked whether he was going to make a fuss and this world class specialist said, “There’s no point, it’s happening all the time.
    When you strip out the ‘service ethos’ of the NHS you lose so much. The cost benefit analysis is never done – the hours and dedication that people were prepared to give are slowly eroded away. The targets and form filling remain. Do you know that in reports now you are not allowed to write initials but have to write medical terms in full?
    What worries me is that I maybe wrong. Once the ‘ship is prepared for sale’ we may not have to wait for another government. The temptation of selling off Foundations a couple of years before the next election may be too tempting financially and ideologically for a leadership keen to give tax cuts prior to an election.
    There is nothing wrong in using this kind of language. It’s called campaigning. It’s what makes me a rounded human social being. Wink.
    B

  • Evan Harris 14th Apr '11 - 3:58pm

    @tabman 12.26pm

    Thanks for your partial agreement

    “[increases in real terms spending are] one way of releasing more money for patient care; there are two others. One of those is to re-prioritise existing spending, and the other (and none of these are exclusive) is to spend existing money more efficiently. Now, Dr Harris, put your hand on your heart and tell me that the NHS is run as efficiently as it can be and that there is no waste in the current set up.”

    As you say they are not mutually exclusive. No-one thinks you shouldn’t try to be more efficient – hardly worth saying – at any level of funding and I’d already talked about rational rationing (ie reprioritsing) but as well as that I think we should allow the public to choose to invest more in NHS via fair taxation.

    @Ben 12.30pm

    It was a question that needed answering as Labour are always asking it, including some MPs who never rebelled even at report stage against Labour’s follies!

    @ Bill LeBreton 12.55

    I would not describe White Paper or the Bill as a proposal to privatise the NHS. But they would – unamended – lay the ground for NHS-funded provision to be gradually provided by non-NHS providers and even for the conversion of commissioning groups into competing social insurers. Not by this Government but by a future Tory or New Labour Government.

    I share your concern about about the bill and the danger to the party if it is not amended to remove the marketisation and restore democratic accountability. The party Grassroots are seeking to help the MPs and peers stop it so I hope you will sign that petition here http://socialliberal.net/sign-the-statement/

  • david thorpe 14th Apr '11 - 5:38pm

    Evan
    In my own simple way I would regard my self as a supporter of the Economic Liberals within the party. I dont believe there is such a thing as an ‘orange book liberal’, as the various contributors to that book have a range of opinions on different issues and dont agree with each other on all matters of policy and principal. For example, steve webb is not in the same place economically as David Laws, and indeed steve is in a different place to others on social questions.
    I raise that, not because I want to get into a debate on ornage book vs social liberal, but rather because I think to use orange bookers as a colletive term is not quite accurate.
    One key area in which I think the NHS could become more efficient is in the area of procurement, I know of a company which supplies the NHS, it supplies three different primary care trusts within its area, and none of the three recieve any discount for buying in bulk, simply because their individual orders are too small, wheres private companies ordering less than combined orders of the three PCTs combined do receive a discount.
    If a national or super regional office for the NHS was set up, this cwould allow for economies of scale and enable the budgets to go further.
    Indeed one of the major flaws with the heakth bill is that it ignores the governments quest for econoimies of scale in procuremnet in other areas of the public sector. This commiment was shown by the commisioning of a report from Sir Phillip Green into the matter.
    The ammendments proposed by Shirley Williams should be the minimum negotiating point for Lib Dems on this

  • Stephen Donnelly 14th Apr '11 - 9:53pm

    @Tony Greaves
    Posted 14th April 2011 at 2:15 pm | Permalink

    “The question is whether the core business of providing health services should be carried out for profit…..

    At the margins, it is possible to contract with specialist suppliers of health services and some of those may be for-profit companies, without compromising the basic principle (though each case has to be looked at very carefully to see whether there is indeed overall an advantage). But the commissioning body and the core operation is not for profit, or should not be. And the bulk of services should not be provided for profit…..”

    I really do not understand the prejudice against for profit companies. I agree that core commissioning should be not be for profit but, if they can be contracted in such a way as to improve the overall provision of health services, why should private suppliers be restricted to the margins ? Why not choose the best provider ?

  • david thorpe 15th Apr '11 - 2:07pm

    doctors should not try to protray themselves as the gaurdians of the NHS, they had to have their mouuths stuffed with gold to get their cooperation to set it up in the first place

  • Hi Evan,

    I got a message this morning from Lib Dem HQ asking me to take part in a member survey. I responded as follows. I thought you might care to comment:

    > Hello Stephen,
    >
    > One main reason I was willing to support the Lib Dems was the constitution,
    > which I was told meant that the policy decided by the members would be the
    > party’s policy. Liberal DEMOCRATS you see.
    >
    > But that hasn’t happened in practice. The party machinery has been hijacked
    > by its right wing.
    >
    > Another main reason I was willing to support the Lib Dems was the phrase in
    > the constitution about not being slaves to conformity. LIBERAL democrats you
    > see.
    >
    > But now they have got into power they are just as enslaved to conformity as
    > the other parties.
    >
    > My touchstone issue is drug law reform. You know what the party policy on
    > that is, and you must know that the LibDems in power have done and will do
    > nothing to implement it. So we see that in practice the party is not
    > liberal, not democratic, and that’s why I am no longer a member.
    >
    > Goodbye, and thanks for all the false hope.
    >
    > Bernie R

  • Yes, I should have realised, there was a return address, communications from the party are exclusively one-way.

    That’s something else that has really infuriated me recently, a stream of propaganda flowing into my mailbox from some “E-marketing” organisation, which I can’t respond to. The party telling me what to think instead of the other way round.

  • david thorpe 20th Apr '11 - 11:53am

    @ bernie

    the party continues to be government by its ocnsitution, the conference makes policy.
    as for reform of narcotic laws, get an overall majority lib dem government and then see what happens

  • david thorpe 20th Apr '11 - 11:55am

    and MPs from all ‘wings’ of the party have voted against the party position and have done so since the day the pary was founded

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