Wednesday, 27 March 2013

Will 1 April mark the beginning of the end of England’s NHS?


Today on bmj.com, two professors debate whether the NHS reforms, which come into play on 1 April, mean the end of the NHS.

David Hunter, professor of health policy and management at the School of Medicine, Pharmacy and Health at Durham University believes that the “NHS will never be the same again” and that the changes, which are like nothing seen before, “should not be underestimated”.

Professor Hunter writes that once the Section 75 regulations in the Health and Social Care Act 2012 are passed they will allow competition to “freewheel” as more and more services will be put out to competitive tender, consequently “embedding market competition as the driving force in the NHS”. As such, he believes the NHS will begin to run under a different set of values which will “not be in the public interest”.

He says following a “marketization” programme in Sweden, profit-driven health services increased inequities with big cities and high income earners being favoured over rural areas and low income earners. Low income patients had reduced access to primary care.

Professor Hunter concludes that if we are to save the NHS, a public debate is urgently required on "where markets should operate” and “where they should not”.

On the other hand, Julian Le Grand, Richard Titmuss Professor of Social Policy at the London School of Economics, argues that the reforms will not mean the end of the NHS. Instead he says that that there is no need to fear the competition which will provide the challenge needed to improve NHS hospitals.

Drawing in part on his experience as senior policy adviser to Prime Minister Tony Blair from 2003 to 2005, Professor Le Grand says that competition has had a positive impact on the quality of management with “knock-on effects on hospital quality”. He bases these conclusions on research from the London School of Economics, the University of Bristol and elsewhere that found that when more patient choice was introduced in England, hospital quality improved faster in more competitive areas. And he draws attention to research demonstrating that patient choice has the potential to improve quality further.

He also says that the privatisation worry is “odd”, given that large parts of the NHS, including most GP practices, are already private. He points out that many of the new providers will be social enterprises and mutuals; organisations that have a track record of out-performing the conventional private sector.

Professor Le Grand concludes that previous reforms did not lead to disaster or system collapse and instead contributed to a “steady improvement in the quality of care”. If anything signals the end of the NHS, he says, it will not be these reforms but the “Government’s determination […] to impose ill-conceived austerity measures on the public sector”.

An editorial from Clare Gerada, Chair of the Council of the Royal College of General Practitioners, also published today on bmj.com asks what clinical commissioning groups should do on 1 April.

She says that the government’s claims that general practitioners will lead commissioning are "misleading" and while trusted GPs will "bear the brunt" of the public’s wrath, much of the health budget will be handed over to the "for-profit commercial sector" which will lead to services closing and the erosion of entitlements to universal healthcare.

She says that although both Andrew Lansley and Simon Burns said that it was not the government’s intention to force commissioners to put services out to tender, the latest legal opinion says that only in "exceptional cases" would competitive tendering not be allowable and now even the government’s officials "don’t know what to make of the new regulations".

She says that given the current confusion between the regulations and Ministerial assurances, Clinical Commissioning Groups are between a rock and a hard place. She adds that the only sensible, safe and fair course of action is to have a “legislative pause” and for ministers to “revoke the regulations while they undergo proper legal scrutiny”.

Dr Gerada concludes that putting GPs in a position of overlooking the "dismantling of our NHS" is a "monumental betrayal" by the government; one that will damage the trust between GPs and patients.

Also available on bmj.com is Terence Stephenson’s (Professor of Child Health, and Chair of the Academy of Medical Royal Colleges) statement on the withdrawal of the regulations of the Health and Social Care Bill 2012 following a letter to the Health Minister Earl Howe.

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