The government has made a ‘U-turn’, as the media calls it, on reform of the NHS. For Socialist Worker (18.6.11) changes proposed to the NHS are a “retreat”, a “humiliating climbdown” for a government intent on privatising. For the Guardian (14.6.11) it is “a compromise that might just heal the coalition”. But in all the words written about the changes the government has accepted from the Future Forum and the so-called ‘listening exercise’ there is often no mention of the driving force behind the reform – the £20bn efficiency savings demanded of the NHS.
The heart and soul of Andrew Lansley’s original NHS reform proposals was to inject even more business sense into the NHS through the formation of new bodies better able to control costs than the existing ones. GP practices were to be grouped into ‘consortia’ to oversee about 80% of NHS spending, holding budgets both tight and inelastic, and would simply be put out of business if they exceeded them. In other words there would be no room whatsoever for the consortia to test the limits of their budgets – they and any existing or new private health providers would be the fall guys for whatever goes wrong, with the health secretary no longer responsible for providing comprehensive health services. It apparently made financial sense, for as small businesses GP practices have already shown themselves particularly good at keeping costs down at the government’s bidding.
One of the important concerns raised was that the increased competition for the cheapest services would undermine joined up care. Now the ‘GP consortia’ are to be rebranded as ‘clinical commissioning groups’ and will have 2 members of the public, a nurse and a hospital specialist on the board as well as GPs. So now everyone is going to work together to plan services in their area? Well, no! That’s not allowed, the nurse and specialist “must have no conflict of interest in relation to the clinical commissioning group’s responsibilities, eg they must not be employed by a local provider” (government document summarising changes quoted in The Nursing Times 21.6.11) although the nurse can be employed by a local GP. The commissioning groups will be advised by clinical senates on how to make patient care fit together. But what of the basic problem of resources?
“The NHS Commissioning Board must be up and running as soon as possible to help with the challenge of saving £20bn through greater efficiency by 2015” (Guardian 14.6.11, summarising Future Forum recommendations).
Privatisation is a state capitalist policy
Privatisation has had an increasing role in cost cutting in the NHS since the 1980s, when tendering for hospital cleaning contracts was used to cut staff and pay. But while private enterprises play a part, the state is the driving force. “The myth that competition has been key to cost containment in the Netherlands has obscured a crucial reality. Health care systems in Europe, Canada, Japan, and beyond, all of which spend much less than the United States on medical services, rely on regulation of prices, coordinated payment, budgets, and in some cases limits on selected expensive medical technologies, to contain health care spending.” (New England Journal of Medicine, NEJM.org 15.6.11). Cost-cutting comes from government policy, and from state bodies such as NICE (National Institute of Clinical Excellence) which has been established to look at the cost efficiency of medical interventions and propose guidelines for their use – or recommend they are not used.
Competition or the threat of it may play a role alongside regulation to keep costs down, but privatisation has a far more important role in hiding the responsibility of the state for any deterioration of health services. For instance the Unite website carries news items about privatisation dated 10th, 13th and 14th June that do not mention efficiency savings, and a Briefing, ‘David Cameron: a personal guarantee of chaos’ which only mentions it in relation to whether or not the 18 week target is being enforced. But the NHS would not be alright if only it got rid of private companies, workers are not being laid off because of privatisation but because of the state policy of keeping costs down. Within the NHS each part, each trust, each purchaser or provider, is set against the others in the competition for inadequate resources.
Following the Future Forum recommendations the government has eased off its privatisation rhetoric. Monitor, one of the NHS regulatory bodies, will no longer be there to promote competition, but will also be concerned with ‘choice’ and collaboration, while still policing the same rules on competition. Meanwhile the private sector will not be able to ‘cherry pick’ the most profitable services – how much this comforting incantation actually means when there are already private companies offering limited services at competitive prices, for instance routine but not urgent medical investigations, is a moot point. They cannot offer a comprehensive service, but one which is cheaper in the short term – which is what the state wants – since they are not contributing to long term needs such as nursing and medical education.
The rebranding of NHS reforms may have rubbed off some of the rough edges, and dropped some of the more incredible notions – no-one was ever going to believe the health minister no longer responsible for the NHS – but it is no retreat. To make the ruling class do that will require a much deeper level of class struggle that threatens to overflow the bounds of legality and union control.