Pollock AM. Why the next Labour manifesto must pledge to legislate to reinstate the NHS. openDemocracy. 12 Sep 2017.
This first appeared on the Huffington Post 05 July 2017
Dear Mr Hunt
The 69th anniversary today of the National Health Service is a timely but sad occasion on which to draw your attention to the end of the service in England as we have known it, a service for which you have been responsible for over the last five years – the 29th minister since 1948.
All 28 of your predecessors had a legal duty to provide key health services. The Health and Social Care Act 2012 abolished that duty, and has since given free rein to the external market, building on the internal market introduced in 1990, its development through what are now semi-private NHS Foundation Trusts and the scale-up of the Private Finance Initiative under the Blair government. The dismantling and fragmenting effects of the Act are now being felt in your so-called ‘Sustainability and Transformation Plans’, reported to require £22-26 billion cuts from health and social care costs in five years. These are proceeding in tandem with local government devolution deals made, according to the New Economics Foundation, “between elites behind closed doors, with minimal, and posthoc public participation“, at the same time as the local government finance system is being radically and regressively re-designed, which will increase inequalities.
You are ideologically committed to the market, and the enormous waste of money, lack of strategic planning, and exploitation of staff which implementing it involves may be difficult for you to accept. But you have a moral and political obligation to do so.
We know that the market costs more, as a result of unnecessary services, excessive administrative costs, fraud, denial of care, profits, and other problems – about 30% of health spending in the US in 2009. We know that the £8.7 billion you state was spent on private sector providers of secondary care in 2015/16 – an increase to 7.7% of total NHS expenditure – is a gross under-estimate of how much public NHS money goes to private companies, as it excludes primary care and community and mental health care, contracts between trusts and such companies, management consultants, and legal fees and private finance payments. We know that competing for contracts takes clinical staff away from providing treatment. We know that NHS problems will be further exacerbated by the planned return to PFI (codenamed Project Phoenix) coupled with the Naylor Report on the disposal and further sell of NHS land and buildings.
We know that the market results in dominant providers competing for patients and engaging in risk selection, while fragmenting services.
Cross-party support for lifting the public sector pay cap is welcome but it will not address the inefficiencies of the market or the lack of funding, nor will it help the many staff transferred out of the NHS under commercial contracts to the for-profit sector. Wages and terms and conditions of these staff are not routinely collected.
The 2012 Act marked the end of universality. Under your regressive plans to carve out and shift more health service functions to cash-strapped local authorities as part of the move to STPs, devolution, and so-called ‘integration’, the only recourse under current policy will be to cut and close NHS services, reduce entitlements, privatise care, and allow charging and sale of private health insurance – which is what the private sector is lobbying for.
Scotland and Wales, also underfunded by the Treasury, have abolished the internal market by removing the disruptive elements and made prescriptions free. Scotland has also made personal care free at point of delivery, allowing for integration of health and social care.
We call on you on to face up to the reality of the NHS in England that you have deliberately underfunded and prepared for cuts, closure and privatisation, and to support the NHS Reinstatement Bill.
Allyson Pollock and Peter Roderick
Co-authors of the NHS (Reinstatement) Bill
This first appeared in the Huffington Post UK on 14 March 2016
Written with Peter Roderick, co-author of the NHS Bill
On Friday, the cross party NHS Bill returned to the Commons for its second reading (watch the video). The Bill was filibustered by the Conservatives, and following only 17 minutes of debate, it was adjourned. The second reading is unlikely to continue.
Most people are probably unaware of what’s happening. But increasingly the market is invading. Virgin now has over 300 NHS contracts, and an active litigation department. They have successfully prevented commissioners in Hull from allowing local GPs to run primary care services, and are facing a legal challenge from the local trust in Kent to their £128 million contract because of concerns about patient and staff safety. Meanwhile Monitor the regulator has now issued 114 private provider licences. The amount spent by local commissioners and trusts on non-NHS providers went up from £6.6 billion in 2009 to £10 billion in 2014. Industry analysts estimate the community services market to be worth £10bn-to £20bn annually. Trade unions have described “a surge in privatisation“.
Nick Clegg said in 2010 that “breaking up the NHS is exactly what you do need to do“. It’s a painful irony that this is one of the more successful things the coalition government achieved. Its 2012 Health and Social Care Act, piloted by Andrew Lansley, abolished the duties of the Secretary of State to provide and secure services in accordance with the Act, and to provide listed health services throughout England. The latter was replaced by a duty on over 200 new clinical commissioning groups to make contracts for those services for persons for whom each CCG is responsible and establishing the NHS Commissioning Board (NHS England). NHS trusts were prospectively abolished, with the intention of them all becoming NHS foundation trusts which can now receive 49% of their income from outside the NHS. “Public health” functions were created as two legal categories split between the Secretary of State and local authorities, and carved out of the NHS. Virtually compulsory contractual tendering for providing NHS services was introduced and Monitor’s role as an economic regulator was extended with functions aimed at preventing anti-competitive practices.
But the rot didn’t begin with Lansley’s Act. Ken Clarke started it in 1990 with his great split. He ended direct management of services by health authorities and created “purchasers” and “providers”, turning hospitals into ‘NHS trusts’ with borrowing powers, and their own finance, human resources and PR departments. New Labour built on that by scaling up the exorbitantly expensive Private Finance Initiative, so that for one hospital built we may be paying for two. Alan Milburn paved the way for foundation trusts, and now runs a very profitable private healthcare consultancy, while Lansley advises Bain & Company, which helps healthcare companies with their strategy.
Politicians pushing laws from which they then benefit corrode the political process, and these laws have wasted billions of pounds, year on year. The purchaser-provider split was introduced to open up the market in health services. Providers compete for patients and service income. Lawyers, accountants and management consultants are needed to administer – and challenge – the market, and they can’t do their jobs without pulling clinicians away from theirs. Quantifying the costs of a market bureaucracy is fraught with difficulty, but the costs of a market bureaucracy are significantly more than the costs of a public bureaucracy. The House of Commons Select Committee in 2010 was “appalled” that the four most senior civil servants in the Department of Health could not tell them the cost of the market.The usually-cited figures for NHS administrative costs are about 5% before the 1980s, and 14% by 2005 – whilst in the US in 2009, about 30% was wasted on unnecessary services, excessive administrative costs, fraud, and other problems. Professor Paton puts the extra cost of the NHS market at about £5 billion.
This sickening state of affairs need not continue, but it will unless Parliament passes a law to stop it. The NHS Bill aims to do this, by restoring the duty to provide and returning the NHS in England to full public ownership, as in Scotland and Wales, based on bottom-up proposals developed by current commissioners, trusts and local authorities with patients, voluntary organisations, trade unionists and academics.
The most common criticism of the Bill from those who can’t see the wood for the trees is that the last thing the NHS needs is another top-down major reorganisation. Nobody wants unnecessary disruption, but massive and expensive fragmentation and disorganisation is currently underway and this is appreciated by many who work in the NHS – hence support for the Bill from Unite and the BMA.
Over 62,000 people have signed a petition urging MPs to turn up in the Commons on Friday and to support the Bill. We wait to see whether they are worthy of our trust.
National Health Service Bill. Legal and Policy Briefing for the Second Reading in the House of Commons, on 11th March 2016. 03 Mar 2016. download
Restoring the NHS in England as an accountable public service
Pollock AM. Why the next Labour manifesto must pledge to legislate to reinstate the NHS. openDemocracy. 12 Sep 2017.
Pollock AM, Roderick P. National Health Service Bill. Legal and Policy Briefing for the Second Reading in the House of Commons, on 11th March 2016. 03 Mar 2016. download
Pollock AM. Radical new bill is now the only chance to save our service – so get behind it. Morning Star. 2015 May 6.
On 11 March 2015 12 MPs from five political parties tabled the National Health Service Bill in the House of Commons based on the second version of the NHS Reinstatement Bill.
Brief summary of the NHS Bill
In short, the Bill proposes to fully restore the NHS as an accountable public service by reversing 25 years of marketisation in the NHS, by abolishing the purchaser-provider split, ending contracting, and re-establishing public bodies and public services accountable to local communities.
This is necessary to stop the dismantling of the NHS under the Health and Social Care Act 2012. It is driven by the needs of local communities. Scotland and Wales have already reversed marketisation and restored their NHS without massive upheaval. England can too.
The Bill gives flexibility in how it would be implemented, led by local authorities and current bodies. It would
- reinstate the government’s duty to provide the key NHS services throughout England, including hospitals, medical and nursing services, primary care, mental health and community services
- integrate health and social care services
- declare the NHS to be a “non-economic service of general interest” and “a service supplied in the exercise of governmental authority” so asserting the full competence of Parliament and the devolved bodies to legislate for the NHS without being trumped by EU competition law and the World Trade Organization’s General Agreement on Trade in Services
- abolish the NHS Commissioning Board (NHS England) and re-establish it as a special health authority with regional committees
- plan and provide services without contracts through health boards, which could cover more than one local authority area if there was local support
- allow local authorities to lead a ‘bottom up’ process with the assistance of clinical commissioning groups (CCGs), NHS trusts, NHS foundation trusts, and NHS England to transfer functions to health boards
- abolish NHS trusts, NHS foundation trusts and CCGs after the transfer by 01January 2018
- abolish Monitor – the regulator of NHS foundation trusts, commercial companies and voluntary organisations – and repeal the competition and core marketisation provisions of the 2012 Act
- integrate public health services, and the duty to reduce inequalities, into the NHS
- re-establish community health councils to represent the interest of the public in the NHS
- stop licence conditions taking effect which have been imposed by Monitor on NHS foundation trusts and that will have the effect of reducing by April 2016 the number of services that they currently have to provide
- require national terms and conditions under the NHS Staff Council and Agenda for Change system for relevant NHS staff
- centralise NHS debts under the Private Finance Initiative (PFI) in the Treasury, require publication of PFI contracts and also require the Treasury to report to Parliament on reducing NHS PFI debts
- abolish the legal provisions passed in 2014 requiring certain immigrants to pay for NHS services
- declare the UK’s agreement to the proposed Transatlantic Trade and Investment Partnership and other international treaties affecting the NHS to require the prior approval of Parliament and the devolved legislatures
- require the government to report annually to Parliament on the effect of treaties on the NHS.