Wednesday, 27 March 2013

More Hunt balls - or so long as you've got your wealth

'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.