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Editorial
Polly Toynbee gets things right so often that even the
Conservative Party has come to see her in a revelatory light. While I
don’t agree with all she says about the NHS and its travails, some of her
insights are very penetrating and deserve further thought. With the recent
brouhaha about GP’s incomes, for example, she has picked up on the
serious compromise that Aneurin Bevan had to make in 1947/48 when he dropped
his original proposals to include primary care within a new, whole-time
salaried National Health Service and had to settle for something much less. As
is famously apparent, GPs came into the NHS as individual, independent
contractors and have jealously maintained that relationship since.
Of course, since virtually all of its business has to be done with
the NHS, the independent status of primary care has its limitations, and there
are those who would vigorously claim that even under these conditions this
‘special relationship’ has brought benefits to both sides. Thus, in
maintaining their independence from specialist control, GPs have been able to
fulfil their much admired role as keepers of the gate to the hospital services.
They would argue too that this contractual distancing from direct official
diktat enables them to protect their patients’ interests (and perhaps
their own as well) more effectively. With an eye to the sorry state of
NHS-employed, hospital-based staff, they claim that their nominal independence
makes them less vulnerable to the sort of managerial kicking that has been
meted out to their consultant colleagues. It is proposed too that were primary
care teams actually employed by the NHS, it would be administratively easier to
sell them off holus bolus to the private sector, or to use the threat of doing
so to whip them into shape
There is enough seeming truth in these assertions to create
substantial resistance to the once alluring prospect of an NHS in which primary
care was to be provided by full-time, salaried health care professionals of all
kinds. They were to work clinically in custom built premises – call them
health centres or polyclinics or whatever - rationally distributed in the
population, closely integrated with public health, sensitive to environmental
threats and health-protective opportunities and transmitting the specialised
needs of that population to a skilled and responsive consultant service.
Consultants and specialists, one visualised, would be based when necessary in
their high-tech centres but by no means restricted to them. Depending on the
discipline involved, they would also operate at community level with free
interaction and even interchange with primary care when desirable and
appropriate.
Paradoxically, at first sight one might argue that some of the
current restructuring of the NHS with the transfer of the control of a large
portion of the locality health budget to primary care is moving in that
direction. In fact in major respects the divide between the primary and
‘post-primary’ (or non-primary) levels of care is being widened.
Any hope of reintegration has first to take account of the enormous barrier
created by the 1990‘purchaser-provider’ split which put primary
care and specialist services firmly on the opposite sides of a transactional
divide. No government intent on ramping up the use of cash incentives to get
its way with the professionals is going to relinquish the use of this control
mechanism.
In fact, government appears to be encouraging this process of
separation and fragmentation by the further introduction of the mechanisms of
the market into NHS structure in the shape of a fusillade of privatising
interventions. In opposition, the Labour Party fulminated against the
imposition of a commercial market structure onto the NHS and mobilised the
enthusiastic support of the public by undertaking to abolish the market when
they came to power. In the mid 1990s, successive Labour Shadow Health
Secretaries scornfully condemned and rejected the use of the Private Finance
Initiative in the NHS and yet almost the first piece of legislation to be
enacted by the new 1997 administration ensured that servicing the PFI debt
would be a first financial responsibility that local NHS funds must meet. The
almost ceremonial signing of a formidable bundle of PFI contracts in the Oval
Office at 10 Downing Street not long after was a thumb to the nose at all of
those “ideologically-driven” protestors, and a portent of things to
come.
In a volte face of almost historic proportions, not only has the
purchaser-provider split, the sine qua non of a commercially transactional
health service, been retained (in England) but the process has been reinforced
by the succession of privatising legislative measures. They have been
succinctly and superbly summarised in a brief Report from Keep Our NHS Public
(KONP) prepared by Alex Nunns, entitled “The ‘Patchwork
Privatisation’ of Our Health Service”. He describes a process of
privatisation by stealth, how “…it is being parcelled up into
bite-sized pieces and handed over to private control bit-by-bit.”
An unacceptable aspect of this process is the virtual exclusion of
NHS initiatives from many service developments so that only private sector
applicants are permitted. The South West London Elective Orthopaedic Centre
(SWLEOC) is a good example of NHS enterprise. Based on Epsom Hospital, the
Centre was founded in an agreement among 4 local NHS trusts which all
contribute to its staffing. It has very successfully met the hospitals’
targets and is probably the largest joint replacement centre in Europe. Its
future is now threatened by proposed new Independent Sector Treatment Centres
and by the system of Payment by Results (so-called) which will make the 4
founding trusts competitors rather than collaborators!
Where does this leave those of us fearful for the future of an NHS
which is the practical expression of a social principle. When the Conservative
administration threatened to subvert the NHS by opening the way for its
privatisation, the Opposition rose in our support. Now to whom do we turn? It
must be to the public who will be the main losers if the NHS disintegrates and
to those working in the health service who can see what is going on. Will
Hutton writes powerfully in the BMJ of 13th January 2007 on
“Why the NHS needs People Power”. He points out the shortcomings of
some of the highly emotionalised campaigns which blow up over particular NHS
issues (though one might take issue with his inclusion of herceptin
availability, autism and MMR inoculation, and Richard Taylor’s fight for
Kidderminster in the same ‘set’). It is difficult to disagree with
the concept of ‘public value’ which he attaches to such
institutions as the NHS, or with his process of ‘deliberative
democracy’ by which the public express their educated preferences and
exercise policy-making control.
Our task must therefore be to convince the population at large
that the ‘public value’ of the NHS will be greatly diminished if we
continue along our present disintegrative trajectory and to mobilise the forces
of ‘deliberative democracy’ to reverse the direction of travel. We
must take our stand not only by showing what is being lost by the current
‘fragmentation by monetarisation’ of the NHS being passed off as
reform, but also the more effective alternatives that could be developed. To
most people working in health care, as in education, the community services and
other walks of life, the social content, shared purposes and moral values of
the working life represent a very important element of the return on working
investment. It is at this level that many of us feel the threat to the NHS is
being directed. It is for us, for social commentators like Polly Toynbee and
Will Hutton and for all the many individuals and organisations with a stake in
the social services of the future to ensure that the voice of the public is
heard and the NHS set back on track.
HARRY KEEN
Guest Editor
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The NHS Consultants' Association
