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| 'There's a waiting list for NHS haemorrhoidectomies these days but if you want to go private I could do your husband's as well with our BOGOF special.' |
April 1 (a sadly appropriate day perhaps) will witness
another major reorganisation of the country’s health services as the Health and
Social Care Act 2012 comes into effect, giving 211 new Clinical Commissioning
Groups (CCGs) responsibility for purchasing all services delivered on behalf of
the NHS.
The transfer of purchasing and commissioning responsibility from
the Primary Care Trusts to the CCGs has been widely described as back door
privatisation, by doctors’ and patients’ groups as well as unions and the
Labour Party, a charge strenuously denied by the Health Secretary, Jeremy Hunt.
As is proving customary with so many of this government’s
‘reforms’ (which is a bit like saying the RAF reformed Dresden), the
regulations were subject to last minute panic changes. Hunt has maintained that the revisions have dealt
with the concerns expressed by doctors and others, but in the view of many – including
the august British Medical Journal – the revisions have not fundamentally changed
anything.
The regulations are complex and probably their precise meaning
will have to be clarified, sooner or later, through the courts. The key issue concerns whether CCGs will be
obliged to go out to competitive tender for every service they purchase. The government line is that tendering is not
always compulsory – GPs and others will be able to decide what’s in the best interest
of patients. But that’s not what the
regulations actually say.
The regulations say
that a CCG must put every purchasing decision out to the market unless it is satisfied that the services
can only be delivered by a “single provider”: patient interests don’t formally
come into it. However, where a CCG
decides there’s only one competent provider, others not invited to bid may disagree
– and in consequence have the right to mount a legal challenge. Not only would these be costly for the CCG, but would also delay the introduction of new service provision.
It would only take a
couple of successful legal challenges (of the kind mounted against the Department of
Transport in the West Coast Main Line franchise tendering fiasco in 2012) before CCGs round
the country would be advised by their lawyers to take the safe route and go out
to tender more often than not. And competitive
tendering is an extremely expensive and time-consuming process, for both the
provider and the purchasing authority.
But perhaps more importantly,
mainstream NHS providers aren't designed for large-scale competitive tendering – unlike
the large and voracious private sector concerns. If one of the big private care firms loses a bid, their scale and diversity
will enable them to carry on till the next one comes along. The same can’t always be said of the existing
NHS providers – in many cases if they lose a bid, they will be in danger of
disappearing. And this raises the prospect that over time
an increasing range of services in any locality will only be available from private providers.
No doubt within the limits allowed by the regulations (and their
lawyers) GPs on CCGs will endeavour to keep patients’ interests to the
fore. But not all GPs will necessarily
be so scrupulous. Recent research by the
BMJ found that almost a quarter of the 2,426 clinical, lay and managerial
members of CCGs' governing bodies had a stake in a private operator of some
sort. In addition, 4% of GPs on CCG boards advised private health firms or
pharmaceutical companies, and 5% worked for a private health firm as well as
working as a GP. (BMJ
investigation of commissioning boards | BMJ). The scope for conflicts of interest is
enormous.
But beyond the tendering issue, the sales-oriented culture
of the private sector has already started to infuse health provision. A recent
report (Zoe
Williams | Comment is free | The Guardian) revealed that two NHS
maternity units are offering what they describe as an ‘enhanced’ service to patients
(or maybe that should read ‘customers’) comprising a pioneering programme of natural
birth preparation ‘…including hypnotherapy’. The fees for this service – oh,
yes this bit isn’t free – are a mere £190 per couple, for those that can afford
them.
Government ministers have consistently denied that their reforms
amount to privatisation. But long before
the last election, the current Health Secretary Jeremy Hunt was one of a number
of senior Tories who endorsed a position paper which among other things argued
for ‘…in effect denationalising the provision of health care in Britain.’ From April 1 it will feel like that’s just what they've done.
