England’s NHS in 2013John Lister May 2013

Disunited KingdomSince 1999, devolved government in Wales and Scotland and later Northern Ireland have meant diverging health care systems

England: testing ground for experimental market-style reforms

Fragmentation, competition, privatisationWales & Scotland: moving back towards integration – market model rejected, services brought back ‘in house’

Free prescriptions

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Since 2000

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Labour govt’s NHS Plan starting point for 10 years of major increases in funding

More staff – nurses doctors, professionalsMore bedsReduced waits to maximum 18 weeksNew hospitals (privately financed through PFI)New structures for commissioners and providers

2008: hit the wall with banking crash

2008 to 2013

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2009 McKinsey report – target of £20bn savings by 2014 to bridge gap between needs & resources

2010 last year of above inflation increases2010 onwards: Tory coalition govt. New drive for cuts and closures (“reconfiguration”)

A&E under pressure: failure of primary and community health care services & social care

Beds and jobs cutMental health budget cut

High profile cuts

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3 year pay freeze for 1 million+ NHS staffAttempts to break up national pay agreementSouth London Healthcare bankrupt: “unsustainable provider regime” invoked

Mid Staffordshire hospitals – scandal followed by administration & cuts. But 55,000 protest

NW London hospitals, etcSocial care cuts (local government cutbacks)Pressure for mergers/ impeded by “reforms”

The meanest of financial times6

Moving towards a market modelUnder Tony Blair, Labour combined increased spending with market-style “reforms”:PFI to finance new hospitals & health centresFoundation TrustsPayment by Results Independent Sector Treatment Centres“World Class Commissioning” – break up community services for private, social enterprise, “any willing provider”

Increasing bureaucratic costs of market

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Tories crank up the paceHealth & Social Care Bill/Act: Far-reaching changeMassive Bill (400 pages), Complex Removes duty of Secretary of State to provide servicesConfusing language (e.g. amendment from “Any Willing

Provider” to “Any Qualified Provider” – but no definition of “qualified”.

New structure: NHS England leading 200+ Clinical Commissioning Groups ostensibly “led by GPs” but steered by Commissioning Support Services

National Commissioning Board (NHS England) with sweeping powers & Local Area Teams

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Creating a competitive marketNHS Trusts to become Foundations (pressure towards takeovers/mergers etc: BUT OFT intervention creates problems)

Foundation Trusts free to make up to 49% of revenue from private medicine & deals with private sector

Regulator and “Cooperation & Competition Panel” to enforce competition (+ integration!)

Regulations to compel CCGs to open up services to competitive tender/AQP

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Regulation and CompetitionCare Quality CommissionMonitorNICEProfessional bodies (NMC, GMC etc)Cooperation & Competition Panel (Monitor)Office of Fair TradingCompetition CommissionEU Competition Law – “right to provide”

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It’s as simple as this!

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What about accountability of non-NHS providers (AQP)?

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Plans to go much further13

Cameron’s new health advisor Nick Seddon is leading neoliberal from ‘Reform’ group, on record as wanting to hand over NHS budgets to private insurance

Plans to enforce charges for “immigrants” using accident & emergency and other health services open way for wider imposition of charges

Personal health budgets and budgets for social care in mental health and elderly care open way to top-up fees – and health insurance

NHS beds filled with emergencies, now delaying elective treatment: will increase use of private care

How long will NHS remain “free at point of use?”