Monday, 7 January 2013

Ideologically driven reform will undermine the NHS

Privatisation of the National Health Service is gathering pace with fears of increasing fragmentation of service provision. A new term has been coined for it: 'atomisation'. The fear is that it will lead to less strategic planning. Planning will be dominated by the market; what's good sells.  More than 100 private firms will be commissioned by the NHS to provide basic services including physiotherapy, dermatology, hearing aids, MRI scanning, and psychological therapy. Doesn't sound too bad does it? I already use a private company to get my hearing aids. After all, it is simply a technical service. What is more important is where it is all heading and why. I expect it will be easier to introduce charges at the point of delivery once such changes are bedded in. And it will be argued on fairness. The arguments will run as they do now on winter fuel payments, free bus passes and child benefit. It will be asked why the wealthy should benefit from these as well as the poor. Sometime down the line it will be like dentists; finding an NHS one will become like a needle in a hay stack.

And this is the biggest problem for the Tories in carrying out the kind of 'reform' of the NHS they would really like. It is the fundamental principle at its core: that treatment is free at the point of access and delivery. It has been a line in the sand since its foundation. But what if you then make access to services the same as prescriptions for medicines. A prescription for physiotherapy  for hearing aids or psychological counselling would be easier to charge. After all it is done already. And all the more readily if you could get the service faster if you paid.

We recall the Tory election manifesto promising no top down reform of the NHS. But let us put that aside. It is an old argument and in any case we didn't believe it. I have never known a Tory government that did not try to 'reform' the NHS; reform usually means some form of privatisation. The big idea in the previous Tory government was an 'internal market'. They believe 'competition' produces greater efficiency. What it often does, however, is to produce 'cost cutting', which isn't quite the same as efficiency. 

Privatisation they also believe will make service provision more responsive to the customer's needs. The patient is no longer a patient, passively accepting poor service delivery, but a 'customer' able to make wishes felt in a market place. But the way a customer does this is, of course, through pricing and choice. And so the argument will run. Wouldn't it be better to put the power of purchase in the hand of the patient? Let them choose what level of service they want. It is a simple step once you have already introduced NHS provision by companies already in the market place. 

There is no doubt that the NHS faces great challenges as it moves forward. It needs to be responsive to needs resulting from demographic change and changing lifestyles. But also it needs to reform as new technology alters medical practice. Population growth, life expectancy and age distribution most obviously produce changes in service needs. But then there are those not so obvious. Many of us will be living alone. By 2032 it is expected that about 40% of the population will be 'living alone' and 1.4 million of these will be 85 or older. It is a sobering statistic and it is clearly going to change not only the demands on health care but how these will need to be delivered. Not because this geriatric population will be necessarily unhealthy.  Far from it, it is likely they will be healthy; why else would they be living so long? But it will change service needs. It will certainly change needs for community services and how these will operate.

What really puzzles me is that the changes being made by the government really don't address these key fundamentals. They are tinkering with the system ideologically without viewing the bigger picture. They are obsessed with the mechanics of it all rather than with its purpose. The government's reforms start with changes in the way health services are commissioned, you then introduce new service providers, you then de-commission the service provided by the NHS (why duplicate) and then where will we be? It is time for honesty. It is time we said what 'atomisation' and 'fragmentation' of the NHS means. 

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