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The fight against the assault on the NHS must come from where the real power lies – from NHS staff themselves...

Just say No to the attack on the NHS


As 2006 begins many people inside and outside the NHS are asking three questions: What is the real state of the NHS, how did it get to be like this and what can we do about it?


If you work in the NHS you know that the answer to the first question is bad. All sorts of services are being reduced, hospital beds are closing and staff posts are being reduced. The famous Royal Free Hospital in London is a typical example of an NHS trust that has instituted a range of cost cutting measures since September to deal with its budget deficit. It calls these measures a new model of care but patients and staff know that nearly 100 beds have closed.

The King's Fund, an independent organisation, which looks at the management of health and social care and largely supports government policy, has openly acknowledged that the end results of current reforms may be closures of major hospitals. It has just published a report called "How Should We Deal with Hospital Failure? Facing the challenges of the new NHS market".

Commenting on both this report and on the recently published annual report on NHS performance, Niall Dickinson, Chief Executive of the King's Fund, said on 7 December: "...the health service faces real financial problems and patient services will suffer unless the government deals with hospital failures better. The NHS is ill-placed to prevent hospital failure from happening and to deal with it when it does happen. ...We would like to see a more rigorous financial distress regime."

Hospital failure? Rigorous financial distress regime? The King's Fund has clearly lost the ability to speak English but we can all understand its code. A number of hospitals are likely to go bust as a consequence of government policy and there is no plan to bail them out. The King's Fund pretends that this is an unintended consequence of government policy but those who work in the NHS know that is the plan.

How did it get to be like this?
The situation is the result of a three pronged attack on the service. More visible since the general election, the origins of all three so-called initiatives pre-date the election.

They are:

Rather like a noxious pudding, it is a case of take the above three ingredients, stir well and add a good pinch of engineered conflict between GPs and the hospital sector and use any opportunity to sow division among NHS staff. A proper understanding of the three elements of the attack is the first step in repelling it. Crucially NHS staff still have significant control over all three elements and if they refuse to implement government policy, then our offensive would begin.

Expansion of the private sector
The particular form that private sector expansion currently takes in the NHS is the Independent Sector Treatment Centre (ISTC). These treatment centres mainly carry out routine surgical work and the Health Secretary claims that they are the key factor in reducing waiting times for surgery. The British Medical Association (BMA) last month gave detailed evidence to the Parliamentary Labour Party Health Committee outlining their impact on health care. Firstly it quoted the government's own data which show that in 2003-04 the procedures purchased under the ISTC programme cost on average 9% more than the NHS equivalent cost (Hansard, Official Report, 16 March; Vol 432, c 273w).

The BMA pointed out there is no evidence to indicate that value for money is being achieved. There are instances of ISTC contracts being paid in full despite a failure to deliver the number of procedures set out in the contracts. In addition the whole business of administering a service from a clutch of small providers is expensive.

The BMA report also analyses how the ISTCs are fragmenting NHS services:

"We would wish to question the logic behind a scheme which sees patients having to travel from Durham to Middlesbrough for an MRI scan provided by the independent sector while an MRI scanner in Durham is idle. Similarly should it be the case that patients in Southampton are expected to travel to an orthopaedics ISTC provider in Salisbury while Southampton's own conventional orthopaedics centre has excess capacity and now in fact has to close capacity due to the loss of work to the independent sector?"

These specific and detailed examples provided by NHS workers expose privatisation for what it is: a device to fragment and close NHS capacity.

Another aspect of the ISTC is the EU inspired scheme which allows the ISTC to take over publicly financed building and equipment such as the state-of-the art operating theatres at the new NHS treatment centre in Birmingham.

Crucially the BMA report dissects the government claim that the ISTCs are responsible for bringing down waiting lists. The ISTCs claim that they have reduced ophthalmic waiting times. However the report points out that the ophthalmic ISTC scheme is only responsible for 3% of the total cataract operations, for example. It is clear that it is traditional NHS hospitals working in new ways that have really made the impact on cataract waiting lists.

The impact of ISTCs on the education of doctors and other health care staff has already been highlighted in Workers. The BMA has now exposed how the government's contracts with ISTCs facilitate this destruction. They have discovered that phase one of the ISTC programme specifically excludes these private providers completely from training responsibilities and there continues to be uncertainty regarding provision of training in phase two. The orthopaedic centre at Southampton mentioned above is now threatened with losing its training status due to transfer of work to the private sector. This example clearly illustrates that this is not a matter of transferring training from one sector to another; rather, the aim is to destroy existing facilities.

Choice of provider
1 January 2006 is day one of the government's choice agenda in the NHS, which means that if you need to be referred to hospital your GP must offer you at least four options about where to go. If the GP is able to offer you 5 options, one must be in the private sector. This options process was meant to be accompanied by a £64 million computerised hospital appointments system called "Choose and Book", which was designed so that a fully trained doctor could sit with you in the surgery and click through the screens and book you in there and then. Needless to say in the pilot the system was found to be slow, unwieldy and the system crashed etc. while the patients in the waiting room piled up. Like many government purchases of US computer systems this one is now behind schedule and has been put back by one year but the choice agenda proceeds without computerisation.

In many parts of Britain there is only one hospital that is easily accessible to a population. When the Consumers' Association conducted a survey on the government's plans, the public overwhelmingly responded that their preferred choice was for their local hospital to be of a good standard even in those areas where a number of hospitals were within reach. GPs have pointed out that most patients will not have the knowledge to choose, and as local GPs they cannot provide detailed information on all the options as they tend to make relationships with their local provider.

Inevitably discussing choices is going to eat into GP time, which could be spent dealing with clinical care. If patients choose the more expensive providers on the list of four, then GPs will find it increasingly difficult to manage budgets in any rational way. In turn all acute hospitals are developing marketing departments (!) to make themselves attractive to the patient. Presumably hospitals who are already struggling financially will have less funds to divert to marketing and hence may find themselves losing customers.

For this charade to work, GPs must willingly engage in the process. This particular absurdity could be rebuffed by GPs simply saying NO. As Dr Richard Varley of the BMA GP committee has pointed out, "GPs don't have a contractual obligation to engage in the choice agenda as defined by the Government."

Payment by results
This third prong of the government attack was first introduced in 2004 and means that hospitals are paid for the work they do at a nationally set price. It replaces the previous arrangement of locally agreed block contracts where providers were paid a set amount, regardless of the work they carried out. Currently the scheme applies only to waiting list operations but there are plans to extend it to emergencies and outpatients from April 2006.

The problem with a nationally set price is that it ignores the different overheads of hospitals and different constraints upon them. For example overheads in teaching hospitals may be higher. Hospitals that are tied into Private Finance Initiatives may be obliged by the consortiums to have set contracts and may not have much freedom to change contracts for services. Crucially, hospitals that already have significant debt charges cannot negotiate a price, which at present helps them to manage that debt.

System suspended
On 6 December three strategic health authorities (SHAs) covering Hampshire, Surrey, Oxfordshire, Berkshire and Buckinghamshire suspended the payment by results system saying they feared it would further destabilise hospitals that are already in financial trouble. Effectively three NHS regions and their senior NHS employees said NO to government policy. As Workers went to press no action had been taken against the SHAs.

So if GPs say NO and strategic health authorities say NO, at least two strands of the attack could be rebuffed. No one can force a GP to send a patient to an Independent Treatment Centre and patients could insist on NHS provision. Despite the scale of the attack, control still rests with working people so long as they wish to exercise it.