Opinion: NHS reforms need careful examination

I am a public health doctor and a member of the Liberal Democrats. I am also, in the words of Gordon Birtwistle, when he spoke in the debate on the new Health and Social Care Bill, one of the “faceless bureaucrats in palatial offices” that he blames for the failings of the NHS. I’d like to put a couple of arguments against the new health reforms, as I don’t believe that as a party we are very well informed about what these health reforms mean.

The reforms of the NHS are a substantial departure from what we had before. There are aspects of the new policy that sound good to many Lib Dems: increased powers to local doctors, taking unnecessary bureaucracy out of the NHS, democratic accountability from local health boards involving local councillors. It’s about decentralization and local decision making. The white paper was called ‘Liberating the NHS’. However the rhetoric seems to differ from the substance.

Let’s have a quick look at clause 16, part 7, subsection C of the new bill. Sorry to get all detailed. But detail counts in legislation. This talks about the relationship between the Secretary of State, the new NHS commissioning board and local groups of GPs, known as ‘consortia’:

(7) the regulations may require the Board or consortia in the exercise of any of its or their functions-

(c) to do such other things as the Secretary of State considers necessary for the purposes of the health service.

Sneaky. That’s a rather catch all clause that doesn’t sound like liberating the NHS to me.

There’s also a claim that we agreed to these reforms in the coalition agreement. This is not true. The coalition agreement is very clear (on page 24): “We will stop the top-down reorganisations of the NHS that have got in the way of patient care.” I’m not sure what this new reorganisation is, but it certainly doesn’t feel bottom up to many of us working in the NHS. This is being forced on us from Whitehall.

As well as departing from the spirit of the coalition agreement, it also deviates from the letter. The agreement says: “We will ensure that there is a stronger voice for patients locally through directly elected individuals on the boards of their local primary care trust (PCT)”. This will be hard to do. The reforms scrap the PCTs.

Most health care professionals who work in the NHS do not agree with these reforms, despite government claims. A survey of doctors by Ipsos Mori for the BMA found that 66% think that the proposed system of GP-led commissioning will increase health inequalities and 61% think the reforms will lead to them spending less time with patients. Other professions are equally critical. The Royal College of Midwives and the Chartered Society of Physiotherapy described the reform as ‘extremely risky and potentially disastrous’. Even respectable charities such as the Alzheimer’s Society, Asthma UK, Breakthrough Breast Cancer, the British Heart Foundation, Diabetes UK, and the Stroke Association have called for changes to the bill, as they are concerned about a lack of accountability.

The proposed reforms promise much about accountability and local autonomy, but they fail to deliver. We didn’t sign up to this in coalition. The reforms may change the health service for the worse. We should not support this.

Felix Greaves is a public health doctor working for the NHS in London. He is a member of Vauxhall Lib Dems.

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39 Comments

  • trevor warner 9th Mar '11 - 3:39pm

    Neither the Lib Dems or the conservatives had these NHS reforms in their manifestos, the Lib Dems are putting minor voting changes ahead of protecting the health service, they will be punished for this total lack of guts at the ballot box !!!

  • Felix please help the people by explaining the problems to those lib dem mp’s who will vote these changes in if the the other bills have anything to go by. I am at the womens tuc listening to woman after woman describing cuts that are already clear in health, including ‘volunteers’ attending women in labour due to lack of midw’ives. Anyone can ‘volunteer’. You just have to have an interest. I expect the moderator will not print this either. The government argues that these volunteers ‘free up time’ to let the midwives get on with something else. I wonder how the women feel when they are in labour?

  • Grammar Police 9th Mar '11 - 3:56pm

    Actually Trevor, the things in our manifesto about the NHS were broadly similar in many respects (more involvement for professionals in commissioning, increased democratic accountability through local health boards, scrapping of PCTs, SHAs). Most people who spout this line have never looked at our manifesto.

    Implementing these manifesto commitments/ a pure ‘Lib Dem’ health bill would require major changes. I actually think it was the coalition agreement that was out of step with our policy on this, when it said “We will stop the top-down reorganisations of the NHS that have got in the way of patient care.” Our own manifesto planned for at least one more!

    There are things in the Coalition’s bill that rightly deserve criticism, but the idea that you can only “protect the health service” by ensuring that no change whatsoever occurs, is hugely conservative thinking, and not why I joined the Lib Dems.

  • The issue is quite simple and that is Tory privatisation of the NHS – it has nothing to do with giving patients or doctors more powers over health care. It is about removing some structural safeguards against privatisation and creating other ones to facilitate the process.

    OK some GPs might be all in favour because they see the profits that can be made by actually sending their patients to facilities that they have a financial stake in. Any reasonable person will easily recognise that the bottom-line for those who want to destroy the NHS has nothing to do with saving money or providing better healthcare – it’s about making money for the shareholders or owners of all the companies waiting in the wings like vultures to pick the NHS clean.

    And once it is detsroyed it can never be put back together again and I suspect that one fully privatised we will find that costs rocket.

    So please spare me useless gestures about fighting the Tories on this by trying to amend the wording of the odd clause – waken up LibDems and fight the Tory ideology that is the driving force here and so far your leadership is supporting it.

    Yea efficiencies can be made in the NHS and yes things can be improved but wholeslae privatisation is not the answer.

  • Excellent article that sums up many of the concerns regarding these changes. The specifics are worrying, it was in neither of the coalition party’s manifestos and is against the coalition agreement. So not only did the electorate not vote for it, it can be reasonably said that the Lib dem special conference specifically voted against some elements.

    I work in Occupationl Health as a Director of a private company. Due to the nature of this I have numerous interactions with both NHS bodies and members of staff. None have been positive about these changes.

    So we have changes the public have not voted for, that are ill thought through and stand to potentially cause massive inequalities in treatment.

    Lib Dems can either support the Tories or follow the coalition agreement and vote against a top down reorganisation. Unfortunately, I suspect it will be the former.

  • Depressed Ex 9th Mar '11 - 4:10pm

    Actually Trevor, the things in our manifesto about the NHS were broadly similar in many respects (more involvement for professionals in commissioning, increased democratic accountability through local health boards, scrapping of PCTs, SHAs).

    So where on earth is “increased democratic accountability” in the current proposals?

    The principle of democratic accountability was actually accepted in the coalition agreement, which provided for elected members on PCTs. But the Lib Dems voluntarily agreed to go along with Lansley’s idea of putting GP consortia in charge instead, so elected members went out of the window.

  • Good piece, thanks. I’ve read many contributions on this bill recently, on this site and others and both opposed and in favour. So far none have persuaded me that these reforms are either justified or beneficial, and it seems likely that once implemented they may cause substantial structural damage to the NHS which could be hard to undo. I hope our MPs will oppose this.

  • @Grammer Police
    I thought I was having a blonde moment for a while, but have just re -read the manifesto and there was no mention of scrapping PCT’s. Health Boards assuming the commisioning responsibility was in there as was scrapping SHA’s.

    PCT’s have functions other than commisioning, for example they employ Health Visitors. And we are not talking about a health board taking on commisioning but private companies who would, I assume, wish to make profit in doing so…..

    It is not always about getting the best value for each service item. If hospitals lose their basic surgery to a lower cost provider, they may not be able to afford to train for and resource more complex pocedures that private companies would run a mile from.

    I don’t think the NHS should stand still, nor do I believe that Labours efforts were all wasted. There were real improvements over Labour’s time (as well as some real balls ups!). Healthcare moves faster than most other sectors and it is right that improvements are identified. But forcing through changes that most of the professionals in the NHS do not believe will help patients is not the best way to go about it.

  • Baroness Williams’ article in The Times describing her four areas of concern about the NHS proposals is also worth reading for those who haven’t yet:

    http://spiderplantland.co.uk/?p=6332

    And the Harris/Williams amendment to the motion on the NHS that will be discussed at Spring Conference on Saturday:

    http://www.martintod.org.uk/2011/03/09/winchester-liberal-democrats-take-leading-role-in-rebellion-against-coalition-nhs-policy/

  • Felix Greaves 9th Mar '11 - 5:19pm

    Thanks for the comments so far.

    I’m not saying that the NHS doesn’t need to change, far from it, but that trying to make the changes in this way is foolish. I agree with Steve Way’s comment. You need to get the people who work in the service, and the people who use it, to understand why the changes are necessary. Piloting any potential changes in one area, and then evaluating whether they work or not, might go some way to doing this.

  • GP The comment “No change is not an option” is made far too often these days, and always in a knocking way, usually about some change the individual doesn’t agree with, or, as in your case, when a change you DO agree with is being criticised. It is an easy get out not to make a proper argument, and should be used sparingly if at all.

  • Emsworthian 9th Mar '11 - 6:28pm

    I don’t know why some people in the party sturdily defend these Tory orchestrated reforms. Is it just that they want to sound governmental and big it up like a party with 40% of the seats instead of less than 10%. The changes are nothing short of potentially disastrous, will not engage the public anymore than previous efforts and are an open cheque for the private sector to make loads of money especially when the heath adviser and the provider are the same business. This was always the Tory’s agenda and it looks like we’re going to help them make it happen.

  • I think it’s worth quoting from the BMA survey of doctors that Felix Greaves linked to on what they think about the proposed changes:

    “89% agree that increased competition in the NHS will lead to a fragmentation of services
    65% agree that increased competition in the NHS will reduce the quality of patient care
    66% agree that the move for all NHS providers to become, or be part of, foundation trusts will damage NHS values
    66% agree that the proposed system of clinician-led commissioning will increase health inequalities
    88% think it likely that the reforms will lead to increased competition, but only 21% believe this will improve the quality of care

    67% think closer working between general practice and hospitals would improve the quality of care, but only 34% believe it likely that the reforms will lead to this
    61% think it likely that the reforms will lead to them spending less time with patients, a change which only 1% would welcome
    33% of respondents are broadly opposed to the reforms, 18% are broadly supportive and 36% say they are waiting to see what happens
    Even within the ‘pro-reforms’ group, 67% agree that increased competition will result in fragmentation of services”

    http://www.bma.org.uk/healthcare_policy/nhs_white_paper/moripoll2011members.jsp

    Why is the Government pressing ahead with these reforms when most doctors think they will result in worse health care provision? I was under the impression that the Government’s policy was to trust professionals to know what they’re talking about…

  • @ Felix Greaves

    Might I go further and suggest that even with your criticism, you are being a little naive as to what’s planned.

    This is a full blown privatision plan as detailed in an article for today’s Pulse. This shows that the government intends that the Any Willing Provider policy to be about wholesale privatisation of care pathways. Pulse report:

    NHS East of England will meet this week to discuss launching pilots of ‘integrated pathway hubs’ in up to six PCTs, with musculoskeletal, respiratory, and frail and elderly care the first three pathways lined up to go out to tender.

    ‘Dr Steven Laitner, a GP in St Albans and associate medical director at the SHA, said the plans could deliver ‘transformational change’ to the NHS.

    Dr Laitner is shared decision making lead at QIPP Right Care, a Government-backed unit set up to spearhead the NHS’s £20bn savings drive. He told Pulse: ‘We’ve got support from the DH and are looking to test this model across the country.’

    He said he envisaged contracts for clinical pathways being taken by multi-disciplinary teams involving GPs, specialists, third-sector organisations and private firms, adding that contracts would ‘align clinical and financial incentives’. Contracts would be more lucrative for GPs and private firms if they cut referrals, he added.

    Further on it continues:

    Ms Parbinder Kaur, project lead for the hubs, said: “The push has come from GPs. They are open to the market coming in with new ideas.” She said a string of meetings with GPs and private providers had shown both had “appetite” for the idea, with the next stage a bidding process for contracts, which are due to go live in April 2012 to fit with the Government’s ambitious transition timetable: “It will involve a competitive tender. We expect this to involve a combination of third-sector, independent-sector and NHS providers.”

    This is compared to the government’s briefing:

    Our plans for ‘any willing provider’ are precisely the opposite. Competitive tendering means identifying a single provider to offer a service exclusively. ‘Any willing provider’ means being clear that a service needs to meet NHS standards and NHS costs, and then allowing patients to choose themselves wherever they want to be treated.

    Anyway, here’s the whole thing…. http://www.pulsetoday.co.uk/story.asp?sectioncode=35&storycode=4128768&c=2

    This article really is a must read for anyone who is concerned about the ‘NHS reforms’. We already know that the Tories are happy to blatantly lie in order to win support.

  • I’m in favour of privatisating healthcare, provided that contributions to the system are paid on a progressive basis and that it’s free at the point of use. But I worry that these reforms will make it too easy for the system to be dominated by anti-competitive behaviour. Too much power in the hands of GPs and not enough in the hands of patients – I can’t see how it’s going to work.

  • But I worry that these reforms will make it too easy for the system to be dominated by anti-competitive behaviour. Too much power in the hands of GPs and not enough in the hands of patients – I can’t see how it’s going to work.

    I don’t see how that is a problem, as long as people can pick their GP.

    As for the BMA etc, I tend to agree with George Bernard Shaw “All professions are conspiracies against the laity”.

  • Depressed Ex 9th Mar '11 - 9:43pm

    I don’t see how that is a problem, as long as people can pick their GP.

    Well, even that isn’t a realistic option as far as very many people are concerned. But if you think about it, it’s CONSORTIA of GPs that are being put in charge, not individual GPs. So you would have to try and find a GP who belonged to another consortium. And God knows how you’re meant to tell whether that consortium would do any better.

    I just get fed up with people continually touting these half-baked, untested pseudo-market solutions, when the party advocated something completely different when it was soliciting votes last year. If people want to espouse Tory policies, that’s up to them, but they should have the honesty to do it BEFORE the election so that the people can decide. Surely that’s meant to be how a democracy works?

  • Stephen Donnelly 9th Mar '11 - 10:10pm

    @Depressed Ex. You make a good point when not being tribal : “CONSORTIA of GPs that are being put in charge, not individual GPs”. One of the more serious flaws in the plan is the potential conflict of interest between GPs as suppliers of primary care and commissioner of secondary care.

    On the other hand the health care system is inefficient and cannot be afforded given the financial mess left by Labour and the increased cost that an ageing population will bring. Reform is needed, and cannot be simply written off as a Tory policy.

  • Being able to pick your GP helps, but it doesn’t help enough to ensure the system is properly competitive. And that’s a good point about the consortia, DE.

  • Depressed Ex 9th Mar '11 - 10:28pm

    You make a good point when not being tribal

    I don’t know which “tribe” you think I belong to. I’ve never voted Labour – or Tory – in my life.

    And as for this stuff about “reform being needed,” why on earth should it follow from that that what Lansley is proposing is a good thing? Particularly when the Lib Dems fought the election last year on a quite different policy, and succeeded in getting a quite different policy into the coalition agreement? It makes no sense.

  • Personally I wouldn’t trust my own GP with a top-up shopping trip to Sainsbury’s – let alone with his share of £80bn a year. My individual experience locally does not inspire confidence. GPs will farm out management activities to profit-hungry corporations because it is not what they went into medicine to do.

    The move to allow more and more private involvement in provision of state funded services flies in the face of the disastrous experience in almost all cases so far. It beggars belief that having suffered the dreadful consequences of privatisation on areas as diverse as hospital cleaning and the railways that we are even considering allowing this to happen again with our health service. With rail privatisation there were dire warnings in advance that no-one listened to because they were so sure the free market was a cure-all and would reduce costs, drive up standards and increase choice. Look what a mess we are in now.

  • “Why is the Government pressing ahead with these reforms when most doctors think they will result in worse health care provision?”

    You could of course have said the same in 1946.

  • Ed The Snapper 10th Mar '11 - 7:12am

    My local hospital is in a deprived area with high unemployment and many crime problems. However, the hospital receives high satisfaction ratings. Why should the way it is run have to be changed? How much will these changes cost? How can I be sure I will receive better service? How can the success or lack of success of these changes be measured? How much will it cost to return to the old NHS system if the new one proves to be less effective?

  • Imposing a system on GPs that they do not think will improve services is very clearly the opposite of liberal and democratic.

    Time and time again we are seeing policies rushed through by the Tories (let’s not pretend that the Lib Dems have any influence, as it would be a lie) that simply haven’t been thought through and are based on nothing more than ideological zealatory; their hatred for those in the public sector knows no bounds and is informed by no evidence or rationale whatsoever. What are the problems with the NHS exactly and how do these ‘reforms’ address them? All we ever hear from the government are simplisitic populist myths about the public sector that simply don’t stand up to reasoning – they might have done 30 years ago, but not after decades of public sector reform. The Country was in a mess by the end of the 70s because of the power of the unions and it’s now in a mess because of the power of the financial services industry – a classic example of economic armageddon (it would have been without the public sector bailing them out) being created in a highly competitive environment. If I were to draw up a list of logical reasons why unregulated markets often fail and a list of evidence to back it up I would be here all day (and that’s just for competitive markets, let alone monopolies and cartels). Our government doesn’t bother thinking about anything though – they are sure they are right in their own mind that private is good and public is bad.

    Let’s remind ourselves of what they think:
    “Letwin: ‘NHS will not exist under Tories’:”: http://www.independent.co.uk/life-style/health-and-families/health-news/letwin-nhs-will-not-exist-under-tories-731278.html

    The only good thing about all of this is that the electorate won’t allow the Tories to govern for another decade after the end of this term of parliament. I can’t see the Lib Dems recovering within my lifetime.

  • Depressed Ex 10th Mar '11 - 8:13am

    Time and time again we are seeing policies rushed through by the Tories (let’s not pretend that the Lib Dems have any influence, as it would be a lie) …

    In general I think that’s pretty close to the mark, but regarding the NHS the Lib Dems have voluntarily agreed to this Lansley plan being implemented INSTEAD of what was in the coalition agreement.

    This is one case in which the lines about “not having won the election” and “coalition being all about compromise” are non-starters. The party will be fully responsible for what happens, and had better be able to defend it.

  • Grammar Police 10th Mar '11 - 9:55am

    @ Depressed Ex – increased powers for local authorities with regard to health and local health watches.

    @ Tim13 – I agree with you, and it was not my intention to merely assert “no change is not an option”. Equally so, “all change is evil Tory privatisation” as many of the opponents of the new bill, is not a valid argument either (for reference, this is not what Felix is arguing – but it is what Trevor seems to be saying, and broadly what EcoJon appears to be saying).

  • Grammar Police 10th Mar '11 - 9:55am

    @ Depressed Ex – my above post is a reference to your first post on this topic.

  • Grammar Police 10th Mar '11 - 9:58am

    @ “Personally I wouldn’t trust my own GP with a top-up shopping trip to Sainsbury’s – let alone with his share of £80bn a year. My individual experience locally does not inspire confidence.”

    And you trust him with your health? I suggest you get a new doctor.

    @ Hywel, you’re exactly right –

  • OK, having read Paul Burstow’s answers at 1:52 in this thread – https://www.libdemvoice.org/paul-burstow-writes-nhs-22806.html – and specifically what he says about Any Willing Provider, I’m now more reassured that it would be a genuine market. As he says, it’s a move away from the rigging of the market under Labour, which has ended up costing so much.

  • @Grammer Police
    “And you trust him with your health? I suggest you get a new doctor.”

    Or perhaps you allow people to do the roles they are most suited to. GP’s already signpost to secondary service, and do a great job the majority of the time. That does not mean they are able to effectively commision those services.

    In my company we have some excellent Doctors and Nurses. They excel at their clinical roles and some take on further tasks they are suited to. We dont have any of these working in accounts. Instead we have a seperate and equally professional team working to get the best value from our suppliers. Our clinical staff will set out the parameters the accounts team need to satisfy with the suppliers, but this is what GP’s already do.

    The biggest concern in these changes is that the relationship between Doctor and Patient can only be harmed. If the GP’s in your area decide a treatment is not cost effective (although it may be offered in other areas) then it is they, and not an external body that is rationing the treatment. GP’s should be the patients advocate not the quartermaster.

    Change within the NHS is certainly needed I just believe these changes will be counterproductive.

  • Depressed Ex 10th Mar '11 - 11:34am

    increased powers for local authorities with regard to health and local health watches.

    We’ve already been round that particular mulberry bush a few times, and it turned out that as far as the NHS is concerned, no increase in the powers of local authorities is being proposed:
    https://www.libdemvoice.org/opinion-health-social-care-bill-a-local-government-perspective-22867.html#comment-163355

  • I would suggest that those who scream “No privatisation of the NHS!!!” should take a look at this: http://en.wikipedia.org/wiki/Healthcare_in_Sweden

  • @Tabman
    So which party put a change to a Swedish type system in their Manifesto ? Their system works well but the Government are not talking about implementing this. For a start the national frameworks ensure there is no health inequality (something lacking in teeth in the current proposals). The changes required to even approach a Swedish style system would certainly come under the top down changes the largest party of Government (who also have the biggest mandate) campaigned against. After 13 years of Governments that ignored the voters after elections do you not think we deserve a bit more of a democratic approach????

    I’m all for giving people the chance to decide the Health Service they want their Government to implement, but I’m hugely against changes without mandate (or indeed any decent planning or contingencies). We’re about to have a referendum on a change that will have far less effect on peoples lives than the changes to the NHS, as no party has a mandate on this why not let the people decide ?

  • @Steve Way

    Well said, however, when you say the Tories have the largest mandate I find it a bit puzzling.

    Not only did they lie their way to the election saying whatever they thought voters wanted to hear and being more opaque than a private equity fund but they also didn’t win which in my view gives them no mandate at all on both counts.

  • Why is it that the reforms don’t tackle the issue of health spending growing out of control and for some reason co-payments maintain their pariah status?

    Surely opening up a service to increase choice, reduce the burden on thee public purse and facilitate greater price competition (new forms of health insurance will emerge and drive drug prices down) is at the heart of the Lib-Dem ethos?

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