Don’t tinker with the NHS. Completely rethink it
Why do both the right and left champion Britain’s health system when it remains inefficient, bureaucratic and sometimes inhumane?
Dr Michael Fitzpatrick
In response to the amendments to his NHS reform bill proposed by the Future Forum, Britain’s health secretary Andrew Lansley has sought to reassure Conservative MPs that ‘the core principles of his reforms will remain intact’.
Lansley is committed to Tory free-market principles in the same sense that his critics in the Liberal Democrats, the Labour Party and the health professions are committed to the values of publicly provided healthcare that were so comprehensively traduced over more than a decade of New Labour marketisation and privatisation initiatives (with the complicity, if not the active involvement, of many of the critics of the Lansley reforms). Just as the left has lost confidence in the state, the right has lost confidence in the market, though both sides feel obliged to keep up the appearance of commitment to ‘core principles’ that they have in reality long abandoned.
As a result, the current debate over NHS reforms is characterised by confusion, cynicism and bad faith on both sides.
The key contribution of the Future Forum, which is made up of both medics and patients, to the coalition government’s health reforms is to offer a redefinition of the concept of competition – one of the core principles of Lansley’s plans for General Practitioner commissioning. Within the capitalist system, competition is a familiar device for driving down prices and concentrating economic activity in more efficient units by forcing less efficient producers out of business. But in the brave new world of the Future Forum, ‘competition’ is presented as a ‘tool for supporting choice, promoting integration and improving quality’.
Far from encouraging rivalry and discord, ‘competition’ will supposedly promote ‘collaboration and integration’. The rebranding of ‘competition’ to embody ‘socialism’ is reminiscent of New Labour’s use of the term ‘modernisation’ to dispel any resistance to the intrusion of market forces into public services. But how can GP commissioners avoid conflicts with providers of hospital services? And if commissioning does not shake up hospital, community and social-care services, how will it benefit patients?
The role of the Future Forum in attempting to improve the public image of the coalition health reforms reflects the enduring legacy of New Labour’s politics of spin. As numerous commentators have observed, Lansley’s presentation of his NHS Bill as a revolutionary transformation of the healthcare system disguises the fact that it continues the process of change initiated by New Labour. According to the social-policy academic and former New Labour adviser Julian Le Grand, the Lansley reforms are merely ‘a logical and sensible extension of those put in place by Tony Blair’. Lansley’s inept hyping up of the scope of his reforms has had the effect of galvanising opponents of the government (though most are likely to be readily reassured by the token concessions and delays recommended by the Future Forum).
The recent BBC Panorama exposure of abuse at the Winterbourne View hospital for people with severe learning disabilities near Bristol suggests that the debate about NHS reform is taking place in a parallel universe far removed from the realities of the healthcare system. This small private hospital run by the Castlebeck group offers expert ‘assessment and treatment’ in a facility offering ‘specialist healthcare and rehabilitation’ for patients whose care is financed by local health and social care services. It follows the model of public-private partnership pioneered under New Labour and now being carried forward by the coalition. The Future Forum endorses the commissioning of services from ‘smaller local organisations’ that provide ‘new innovative services’ and can ‘truly reflect communities’ needs’.
In one of many shocking scenes in the Panorama report, a male staff member sits on a chair pinning to the floor a young woman, keeping one foot on her hand to prevent her from pulling herself up. Yet the Castlebeck regime of cruelty and neglect is packaged in the same rhetoric of choice, empowerment and respect that can be found in every official health-policy document of the past decade. Castlebeck is committed to ‘clinical governance development as a vibrant, active and genuinely useful framework’; ‘service user involvement is part of everyday practice’; it provides ‘person-centred plans and pathways’ and ‘the highest quality support to achieve wellbeing and quality of life’. At Winterbourne View, where Panorama revealed lives of idleness and boredom as well as bullying and brutality, Castlebeck claimed to provide ‘structured and meaningful programmes of therapeutic activity’ (the company had the gall to repeat this statement in its formal response to the Panorama revelations).
The Winterbourne View story reveals that people with learning difficulties are no safer in an institution run by a private corporation financed by Irish racehorse owners than they were in the only recently closed down long-stay NHS hospitals (there have been scandals in such institutions in Cornwall and in Sutton and Merton in the past decade). It reveals that official regulators are not reliable guarantors of quality or even of safety: whistleblowers were ignored by both Castlebeck and the Care Quality Commission (which had inspected Winterbourne View on three occasions over the past two years). Yet Castlebeck continues to promote its ‘holistic approach based on non-aversive behavioural interventions and person-centred planning’, its ‘homely and supportive’ specialist facilities (costing £3,500 a week at 56 locations in the UK), and its ‘robust systems of Quality Assurance as well as Clinical Care and Governance’.
Supporters and critics of the government health reforms are united in a sentimental and complacent outlook towards the NHS that takes no account of the experience of patients at institutions such as Winterbourne View. Though conditions there may be extreme, there have been reports of poor standards of care affecting other patient groups, including the wider population of people with learning disabilities and mental-health problems, the elderly, children, women in childbirth – substantial sections of society and those with the greatest need of healthcare.
‘The NHS belongs to the people’ proclaims the Future Forum. The NHS has ‘worked well, providing high quality, equal care for everyone, free of charge, at low cost’ according to Colin Leys and Stewart Player, radical critics of the Lansley reforms (1). In truth, the NHS has always belonged to the state and it has always operated within the constraints of the market; it has guaranteed a privileged position for the medical profession, it has provided care of variable quality, and it is notoriously inefficient and bureaucratic. Most importantly – and this is the link between Winterbourne View and the wider world of the NHS – the politicians and the public health authorities lack a basic respect for those in need of healthcare. The patients at Winterbourne View are treated in an inhumane manner because those supposed to be caring for them do not regard them as fully human.
The Future Forum casually reasserts the familiar prejudices of earlier health-policy documents against those who are overweight, who smoke or drink more than the officially approved levels of alcohol – categories which account for up to one third of the population. Despite all the proposals for patient involvement recycled by the Future Forum, and whatever the shape of the bureaucracy that replaces the disintegrating Primary Care Trusts, the dehumanising and stigmatising rhetoric of timebombs and epidemics continues to legitimise policies that trespass on the dignity and autonomy of patients.
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