After the health bill: The end of the NHS as we know it
With the health bill passed, the government is now setting about forcing
the market into the NHS. Colin Leys looks at what is likely to happen next
http://www.redpepper.org.uk/the-end-of-the-nhs-as-we-know-it/
Andrew Lansley and the Tories continue to claim that under their plans
to privatise the NHS ‘services will still be free at the point of use’.
But this is seriously misleading. They fail to add a key proviso –
provided the service is still available on the NHS. In reality, a
growing list of services will not be available, and so won’t be free.
This is already happening. People who suffer from a range of conditions
that are not life-threatening, but are often painful and even disabling,
are being told to pay for treatment or go without. The health bill will
make this more common, and taking out private insurance for such
problems will become widespread.
At the same time the government plans to expand the use of personal
health budgets, administered for us by ‘intermediaries’. Coupled with
the normalisation of private health insurance, personal health budgets
could easily become a tax-funded subsidy for private healthcare for the
better-off, triggering a further contraction of free NHS care for the
poor. New charges or ‘co‑payments’ also look likely for some aspects of
NHS care.
It has become urgent to see how this chain of developments is likely to
evolve.
Under the bill, clinical commissioning groups, or CCGs, which are
unelected and unaccountable, only need arrange for the provision of
hospital or community healthcare services that they consider necessary
to meet patients’ ‘reasonable requirements’. There will be limits to
their power to restrict coverage, but since the justification for
introducing CCGs is supposed to be that GPs ‘know what patients need’, a
good deal of discretion is going to be left to them. And the private
sector ‘support organisations’ that are going to do most of the actual
work of commissioning will urge that the list of treatments the CCG will
pay for should be kept as short as possible, both to save money and
because their personnel will tend to favour private provision.
Services are already being withdrawn
It is already happening, in a semi-secret way. The practice began in
2006 when a primary care trust in Croydon, desperate to save money, put
together a list of 34 procedures it considered ‘not necessarily
performed for medical reasons’, which it said did not have to be offered
to patients in cases where they were ‘ineffective’ or cosmetic. The list
included non-cosmetic procedures, including surgery for cataracts, hips
and knees, on the grounds that the benefits were minimal in ‘mild’ cases.
Obviously, what is considered a ‘mild’ case of a cataract or an
arthritic hip or knee is liable to be modified by financial pressures
and by April 2011 the Croydon list was being widely used to save money.
According to one well-informed commentator at the time, in some areas
only “urgent” treatments – cancer, fractures and A&E – were funded. All
other procedures were either delayed or the patient was denied funding.
So the ‘postcode lottery’ that used to apply to some prescription drugs
now applies to some treatments, or even whole medical conditions, such
as varicose veins or disfiguring skin conditions. Some of the conditions
listed may sound unimportant, but to a person who suffers from them
denial of treatment is far from trivial.
Besides these services there are others that are supposed to be
available but are increasingly being denied in practice. Some GPs have
been restricted to making four referrals per week, regardless of how
many patients in need of a referral they may see. Other GP referrals are
intercepted and denied before they reach a hospital specialist. This is
being done, explicitly to save money, by privately-run ‘referral
gateways’. One of the first was in west London, where the giant US
health insurer UnitedHealth has been given the job of vetting, and in
some cases overturning, GPs’ judgements.
One west London patient, who had been referred for a replacement after
her knee collapsed, was told by the referral gateway to have
physiotherapy and painkillers instead. It took more than £1,000 worth of
private x-rays and surgeons’ opinions for her to finally prove that she
needed a knee replacement and get it done on the NHS. Many patients are
less fortunate, or determined. For them, NHS treatment is not free. They
must pay to get it privately, if they can. If not, they don’t get treated.
As a result of the health bill, it may not just be GPs’ referrals that
are diverted or denied. The more expensive treatments recommended by
hospital specialists, which the CCGs are going to have to pay for, could
also come under review, and the CCGs could refuse to pay – just like
healthcare maintenance organisations in the US. (Remember the doctor in
Michael Moore’s film Sicko explaining to Congress how she was paid a
bonus related to how many treatments she denied?)
Personal health budgets
Another major change already taking place, and which may have crucial
consequences as a result of the health bill, is the rolling out of
personal health budgets. At the moment these are to be allocated to some
53,000 people in England who are receiving NHS continuing care for a
chronic condition. The personal budgets already used in social care have
revealed their inherent problem: they are limited – and financial
constraints mean that they are not generous. If a personal budget proves
inadequate, the patient has to top it up – if they can afford to. For
NHS care, such ‘top-ups’ will be payments for what was previously free.
It is significant that the government describes patients in receipt of
continuing care as the ‘first group’ to be eligible for them, implying
that personal budgets will be extended to other sorts of patient. The
NHS Future Forum, set up by the government in April 2011, went further,
recommending that, ‘Within five years all those patients who would
benefit from a personal health budget should be offered one.’ The
government accepted the forum’s report, and the Department of Health’s
impact assessment for commissioning speaks of every patient having a
budget allocation.
This raises the possibility that personal health budgets, with
personally-paid top-ups, will become the basis of most, or conceivably
all, NHS care. This approach is strongly backed by advocates of health
insurance. They propose that everyone should have a personal health
budget, sometimes called a ‘health protection premium’, paid for by the
state, equivalent to the NHS’s average annual spending on healthcare per
person. This would entitle everyone to a defined package of
entitlements. Anything beyond that would have to be paid for by the
individual. For most people that would mean taking out medical insurance
for a wide range of other conditions and treatments – if they could
afford to, and if insurance was available (pre-existing conditions may
not be insurable).
Since 2010–11 the funds distributed by the Department of Health for
spending on patients’ acute (hospital) care have been calculated on the
basis of the actual health status of every single patient registered
with a GP, as reported annually to the department – in just the same way
that insurance companies assess whether to offer someone insurance, and
if so for what level of premium. This makes a wholesale shift to private
healthcare via personal health budgets even easier to manage, especially
since insurance companies are going to be involved in the commissioning
support groups that will be handling all such data.
The normalisation of private health insurance
To see how this could work, we must start by noting that in 2009, 10 per
cent of the UK population already had some form of private medical
insurance. This proportion had been more or less static for several
years. Greatly increased NHS funding from 2002 onwards had led to a big
drop in waiting times and other improvements, which reduced the main
incentive to ‘go private’; and then the 2008 financial crisis cut
people’s spending power, leading to a small decline in the numbers
privately insured.
The insurance industry is confident that there will eventually be a big
increase in demand as a result of the health bill. The targets of the
costly advertising campaigns recently mounted by health insurance
companies are not the rich but people in ordinary jobs. The companies
clearly expect private health insurance to become widespread and normal.
This could then easily mesh with personal health budgets to produce a
state-subsidised private health insurance system. It would work as
follows. Personal health budgets will usually be held and administered
by ‘intermediaries’, as they mostly are in social care, and the
intermediaries could be insurance companies. Patients with NHS personal
budgets held and managed by these companies could then have full private
health insurance, with much of their premiums covered by their personal
health budgets. They would only have to pay the difference.
This would leave CCGs with the uninsurable patients – those with costly
chronic illnesses, and those too poor to pay any premiums. And since the
CCGs would no longer have the unspent personal health budgets of the
healthier and wealthier patients, who would have been cherry-picked by
the insurers, the result would be further restrictions on care for those
who remained.
The government will also be under pressure from private providers and
the Treasury to allow charges or ‘co-payments’ for some aspects of the
NHS care that would still be available free. These would probably begin
with charges for consulting a GP and for the so-called ‘hotel costs’
involved in being in hospital, both of which have long been urged by the
advocates of privatisation. If and when this happens, the principle of a
comprehensive, universal free service will have been comprehensively
abandoned.
Colin Leys is an honorary professor at Goldsmiths University of London.
He is the author of Market Driven Politics: Neoliberal Democracy and the
Public Interest and, with Stewart Player, The Plot Against the NHS
(Merlin Press, 2011).
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