Ministers wash their hands of the NHS
If you are confused about where the government is taking the
health service, do not blame yourself. So are many health
service chiefs
Malcolm Dean
Guardian, Wednesday October 5, 2005
If you are confused about where the government is taking the
health service, do not blame yourself. So are many health
service chiefs, as a succession of Chatham House dinners -
where facts can be reported but not the identity of the
people making them - held at each of this year's party
political conferences has confirmed.
Part of the public confusion arises from the row over a
second wave of treatment centres for elective care, now
under negotiation with the private sector. As the health
secretary, Patricia Hewitt, frequently asserts, the first
wave treats just 3% of elective surgery - cataract
operations or orthopaedic work such as hip or knee
replacements. By 2008, when the second wave will be in in
full operation, this will be 10% or just 1% of total NHS
spending. The proportions are small but given the size of
the NHS budget - £90bn by 2008 - the contracts are large.
This second wave is for £3bn over five years.
The main row over the private treatment centres is that
ministers have broken their original rules. These were that
they should add capacity and not rob the NHS of medical
staff or facilities. These rules were followed in the first
wave but controversially broken in the second. Private
companies will be allowed to not only poach NHS medics and
nurses, but NHS premises too. In the words of an NHS trust
chairman, whose centre is being taken over, "It stinks."
But rows over treatment centres have diverted attention from
a much bigger shift. Private operators are not being
confined to elective care. The whole system is being opened
up. Ministers firmly believe that competition will increase
NHS efficiency. A silver halo has been placed above the
private sector's contribution. In Hewitt's words to this
paper: "I have lost count of the number of hospital chief
executives who have told me the presence of a specialist
treatment centre down the road has been the key to unlocking
change in their consultants' performance."
But Hewitt is not comparing like with like. The grip that
orthopaedic surgeons held over their work - the longer the
NHS waiting lists, the better their private practice - did
need to be broken. But to believe the same benefits will
accrue from applying competition across the board is wrong.
In particular areas, yes. GPs sitting on huge pay rises -
almost half now earn £100,000 - need gingering up to make
their surgery hours are more convenient to patients.
But some 70% of NHS resources are spent on long-term chronic
conditions, most of which cannot be cured but with good
integrated care can be controlled. This requires cooperating
coordinated care not competitive fragmented practices. Yet
in a succession of moves more competition is applied.
In July came plans to divest primary care trusts of their
services - district nurses, health visitors, occupational
therapists, family planning, asthma/diabetes clinics - and
open them up to private bidders. Where once Labour had the
support of this large workforce, it has lost it. Then, in
2008, a new health market opens in which NHS patients will
be entitled to select any hospital, public or private, that
can work within NHS cost limits.
The chancellor, Gordon Brown, has rightly claimed that
markets in healthcare are inefficient, contain imperfect
information and set the wrong priorities. The new market
will involve a steep rise in administrative costs, an
erosion of shared values, and still involve private sector
failures. Have ministers forgotten hospital cleaning?
Where the NHS is heading is a retreat from management. This
will absolve ministers of blame - as happened under the Tory
internal market - but at an unacceptable cost. One shadow
Conservative spokesman used to talk of turning the NHS into
an insurer, not a provider. Labour is doing just that;
unless, of course, Brown should choose to intervene.
· Malcolm Dean is the Guardian's leader writer on social
affairs.
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