Why the NHS reforms should be opposed

This is my summary of the main reasons I’ve so far gathered for opposing the 2011 NHS reforms. Thanks to everyone for pointing me to sources on the web. I hope I’ve managed to capture most of what people have said to me.

To be clear, this blog is not about the problems with the reforms, which are legion (and a couple of the sources below deal more fully with this). This is about why we should object to these reforms now, when the move to competition and increased private sector involvement has been going on since the mid-2000s.

So here are the reasons, in no particular order:

1. The Conservatives promised no more ‘top-down’ reform in the NHS, and the NHS was not a major part of the election campaign.

This reason points to the lack of legitimacy for the reforms. Do you remember Cameron saying he could give his main priority in three letters – ‘N, H, S’? Because the reforms were not debated or discussed at the election in any major way, and were not clearly presented in manifestos, they lack legitimacy.

2. There were considerable differences between what was proposed in the White Paper, the first versions of the Bill and the present version of the Bill (such as it is).

This suggests that Conservatives really don’t know what they are doing. A charitable explanation would be that they’ve listened to feedback, but the problem is that they’ve gone from a reforms that look liked they were a marginal continuation of what Labour proposed (White Paper) to more radical market-led proposals (first Bill) to a monstrous behemoth that is more bureaucratic and unwieldy that what it is replacing (second Bill) but still looks like it is primarily about getting more private sector contracts to friends of the Conservative Party.

In summary then, the proposals are a mess, and bordering on the incoherent, with the only main aim seeming to be to achieve more private sector involvement.

3. The reforms are a reckless at a time of austerity.

There are a number of dimensions to this claim. First, there is the cost of the reforms themselves which will be somewhere between £1bn and £2bn, and, depending on who you believe, possibly more. Then there is the disruption to NHS staff, who are going to be made redundant and skills in commissioning that have been built up over ten years potentially lost. Next there is the promise from the government to cut back on quangos, but their subsequent rebirth in the compromised NHS structure, and giving the sense that we might just be reinventing the same structures as we had pre-reform after disrupting all the staff employed within them. Then there is the way that the reforms were implemented through heavy-handed messages from the centre before they had even been agreed in Parliament, so that PCTs are selling buildings and not renewing leases before their successor organisations have even been created.

This is all massively reckless and wasteful in terms of money and people’s lives, all to little apparent gain (except maybe for private healthcare providers).

4. Because of their vested interests we don’t trust the Conservatives to reform the NHS.

As noted above, and elsewhere on this blog, many of the changes the Conservatives have put in place have strong links with Labour’s plans for the NHS (and it’s about time Labour found new plans frankly). However, what is different is that we assume that the reforms are now in bad faith, designed to get more private organisations into healthcare because those are the funders and friends of those in power. Not it’s hardly as if Labour’s hands are clean on this front in terms of advisors and ministers going to work in the private sector, but it does seem that the Conservatives are careless, or even proud, of their relationships with private health providers who stand to gain considerably from their reforms. This gives us the right to be suspicious and sceptical – especially given the problems above.

5. The whereas Labour’s reforms can be seen as an attempt to increase care capacity in the NHS, the new reforms are trying to undermine public provision.

Despite some of the claims made about competition having existing in the NHS since 2006, the small private entry is perhaps best thought of as a subsidised expansion of NHS care capacity, reducing waiting lists in treatments where ISTCs have appeared. However, increasing private entry beyond a certain point will mean that public hospital costs bases will be undermined – NHS hospitals (especially new PFI ones) were built on assumptions about working at high capacity across all specialties, and if this turns out not to be the case, there is a danger of public providers not being able to cover their capital costs. The extension of private provision beyond a point where it provides extra capacity, and becomes a competitor for NHS care, will reduce NHS provision of the relatively straightforward treatments the private sector can compete with, and undermine the cost basis of NHS hospitals as a result.

Many of the private providers in the NHS marketplace were effectively subsidised by the Labour government to enter the NHS (receiving guaranteed minimum private contract sizes and full tariff payments at a time when public providers did not receive them). That they now threaten to undermine public provision is unfair.

6. We only really realise now reform is taking place how much change has already occurred.

A variation on the arguments above is that it took an election and break from Labour to reassess where the use of the private sector was taking us. Many of the Conservative’s reforms are continuations of what Labour were doing while in office – but that doesn’t make them right. There are campaigns that have spanned both Labour and Conservative governments, but the awful way the Conservatives have dealt with their reforms has led to more people becoming aware of exactly what is going on in the NHS, and that has created an opportunity to mobilise opposition against the reforms that we should make use of.

7.  The reforms have made selective and misrepresentative use of evidence and have no chance of working.

What has annoyed a lot of people is Lansley and Cameron’s (and others’) claim that the reforms are evidence-based. Ben Goldacre was pointed out the holes in such claims in his Bad Science column (http://www.guardian.co.uk/commentisfree/2011/feb/05/lansley-use-word-evidence and http://www.guardian.co.uk/commentisfree/2011/feb/12/bad-science-ben-goldacre-nhs)

That’s not all. Elsewhere on this blog you’ll see me looking at research by Zack Cooper cited by the government as showing that competition in the NHS works, but which simply doesn’t. If researchers are going to make claims that they have some kind of magic bullet to NHS reform, then we have the right to be very wary, and they have an onus to prove their case far more strongly than they have done so far (http://abetternhs.wordpress.com/2011/06/29/competition/.)

Then there are repeated claims about clinical problems within the NHS and the benefits that reform might bring. You can find these being taken apart at:

http://justanotherbleedingblog.blogspot.com/2011/04/nhs-reform-from-liberating-to.html

And at https://sites.google.com/site/nhsfuture/Home/debunking-the-myths you’ll find a comprehensive list of refutations about claims that the government have made about the NHS reforms at one point or another.

So, in sum, claims that the reforms are evidence-based need to be treated with a great deal of caution.

So what to do? After just over a year in government the Conservatives have created an awful mess. Because of the heavy-handed way reforms have bee implemented before the Bill was signed off, we have chaos and no clear path forward. It seems to me we are reduced to trying to patch up the Conservative’s mess rather than trying to put in place a careful programme of incremental and democratically agreed reform that the NHS now needs. We should be even more angry with the government than we are.

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7 Responses to “Why the NHS reforms should be opposed”

  1. Dr Am Ang Zhang Says:

    Well written.

    I seems that some part of the NHS has been privatised whether we like it or not including a number of secure mental health units. This is dangerous as mental illness is not easy to have a clear view of chronicity and cure rate (not like hip repl.) and is open to abuse by private org. esp. when the one paying is the State and not Private Insurers.

    Allowing private providers to provide NHS service is full of pitfalls and that includes NHS111.

  2. Jules Storr Says:

    Great piece, but how do we articulate this more widely to the man/woman in the street? Difficult one when dealing with the king of PR. Thanks for some inspiration and points to use whilst doing my bit.

  3. Ian Greener Says:

    Thanks Jules. Hard stuff to communicate, but I think the problem is wider – we have a poor level of public debate around healthcare in this country. Take this piece from today http://www.telegraph.co.uk/health/healthnews/8703065/NHS-funds-weight-surgery-for-obese-man-despite-court-loss.html – which would seem to read as if the evil PCT is denying the man treatment, without any discussion at all about what doesn’t get funded as a consequence of the decision to treat here.

    I think we need to be saying that these reforms were a solution (more use of private sector) being put in place at a time when public confidence in the NHS was at an all time-high, and which none of us voted for in the election. They are ideology with no electoral mandate.

  4. Kate Thomson Says:

    Thanks,Ian, great summary of reasons we need to act + resist. Although the electoral mandate point is actually very important, I am not sure that it will be the one to capture the public imagination- after all, we are probably all pretty jaded and maybe it’s expected that politicians will ‘do what they want’ once they’re in. What is a grave concern/ unholy mess is that restructuring is already happening before reforms have been enacted. Positive spin-this gives the lie to gov hints that NHS is an unwieldy monolith full of people who are resistant to any change(!)Finally, I hope that evidence about gov members’ own interests in growth of private competition can be used to galvanise resistance.

  5. David King Says:

    Thanks Ian for this really clear and helpful summary of the state of the debate.

    However, one question that I keep coming back to and haven’t really seen answered anywhere in recent months is what an alternative vision for the NHS in England might look like, around which those opposed to the government’s proposed legislation might coalesce?

    Most of the debate is framed in terms of negatives – private competition harmful, large-scale re(dis-)organisation bad, evidence base for changes non-existent, and so on. I wonder if the opposition to the health bill might gather more momentum if there was a compelling view of what we want our NHS to actually be like. I fear though that there is no popular consensus and many of our health leaders and commentators continue to disagree publically and privately about the big polar questions: public/private mix, central/local control, managed service versus market mechanics, clinical or managerial authority, balance between investing in quality and achieving productive efficiency, etc.

    Perhaps the best we can hope for is a consensus view that the NHS was doing OK as it was (ie not perfect, but good enough and improving) and that significant primary legislation is not and never was required. The systems and structures that were in place were (and still are?) serviceable and the real energy should be directed to improving patient quality, outcomes, equity and system efficiency. That way everyone can turn their attention back to the things that really matter!

  6. Ian Greener Says:

    Hi David, Muir-Grey has written on this recently (search for him on the BMJ blog), and I think what he says is largely right. I’ve also had a couple of short goes here, particularly at https://t1ber1us.wordpress.com/2011/07/25/if-markets-arent-the-answer-to-nhs-reform-what-is/.

    Best,

    Ian

  7. Flashback and data dump: End of August, end of summer, mail-out of of mental health, health and social care news,views and opinions « Launchpad: By and for mental health service users Says:

    […] they cried for. Some learned, evidence-based reasons against the NHS reforms as (still) framed are here. Competition in healthcare: the risks. And just what would the NHS have to look like for […]

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