(National Health Care System
in Great Britain)
by Allyson Pollock
New Internationalist magazine,
Since its birth in 1948 Britain's National
Health Service (NHS) has been a model for the rest of the world.
It's been a national system of publicly owned and accountable
hospital and community services funded from central taxation -
where hospital doctors and nurses are salaried, under national
terms and conditions of service.
Universal healthcare, provided free and
fairly, released the population from fear of the risks and costs
of care. Before the NHS more than half the population - mainly
women, children and the elderly had no health coverage.
However, a relentless concern with cost-cutting
and market-defined 'efficiencies' over the last two decades has
drastically eroded the central premises of universal healthcare
in Britain. The undermining of central taxation as the funding
base has been accompanied by governments shifting the costs and
risks to patients and their families. The internal market introduced
by Margaret Thatcher in the 1980s was the most visible aspect
of these changes, but Tony Blair's Labour Government has followed
the same privatizing path. The 1948 contract with the people is
slowly being shredded.
In 2000 the Government launched a 10-year
'reform' programme called the NHS Plan which continued the market-oriented,
probusiness policies begun under the Tories. The Blair administration
maintains that it doesn't matter who provides care - so long as
it is publicly funded. And the extra costs of private profits?
They're to be offset by increased efficiency and access, a claim
which has been neither tested nor subject to scrutiny. The reality
is that under the new plan people will pay more tax for fewer
services and be hit with extra patient charges, plus the cost
of private insurance. The NHS will be funder and regulator - but
business will run the show.
Choice and competition: that's the promise.
With 'money following the patient', competition between providers
is intended to improve both efficiency and quality of care. Doctors,
nurses, hospital and community services will be more responsive
to patient needs.
The Government claims that the NHS is
centralized, bureaucratic and inflexible - a claim which has little
evidence other than popular myth to support it. The Health Secretary,
Alan Milburn, talks about 'redefining' the National Health Service:
'Changing it from a monolithic, centrally run, monopoly provider
to a system where different healthcare providers - public, private,
voluntary and not-for-profit - work to a common ethos, common
standards and a common system of inspection... This is the modern
definition of the NHS.'
In 1992 the Conservatives created the
Private Finance Initiative (PFI) as a scheme for luring private
capital into new hospitals, instead of using tax money. It e seems
simple. Bankers. builders and service operators (like cleaning,
catering and laundry firms) produce the cash and in return they
get to lease the building back to the Government or to sell their
services to the hospital. The contract is ringfenced and guaranteed,
usually for 30 years. Predictably these public-private partnerships
have turned out to be a boon for investors but not so good for
the public. Shareholder returns in the range of 15-25 per cent
and the need for profits increase the costs to local communities.
And the private sector's view of 'efficiency' has meant reduced
services and job redundancies. Because the cost of PFI is met
from the annual operating budgets of the hospital, less is available
for direct patient care. The high costs of the first wave of PFI
hospital schemes resulted in a 30-per-cent reduction in beds and
a 25-per-cent reduction in budgets for clinical staff. More than
12,000 NHS beds have closed since 1997.
Low-paid, non-union jobs Britain has also
been exporting this model abroad to Canada, Australia, Aotearoa/New
Zealand and Europe - with similar results. In Abbotsford, British
Columbia, a plan to rebuild the local hospital with private funding
has run into stiff opposition from the Hospital Employees Union.
A report on the scheme by PricewaterhouseCoopers assumed that
collective bargaining rights would be destroyed and that cost-savings
would be based on low-paid, non-union jobs.
Back in Britain in '2000 the Secretary
of State signed a new 'concordat' with the private sector, describing
it as 'a permanent feature of the new NHS landscape'. The agreement
allows private clinics and hospitals to provide the public with
up to 150,000 'procedures a year - things like cataract surgery,
hip replacements or hernia operations. It also allows business
to run NHS hospitals, form joint ventures with NHS organizations
and to recruit overseas clinical teams for existing hospitals.
Alan Milburn has allowed eight private
corporations to bid for public hospitals which don't meet the
Government's draconian performance targets. These are BUPA and
BMI (which together control 70 per cent of the British private
health-insurance market), the Swedish-owned Capio, Interhealth
Canada, Hospitalia Active Health from Germany and the British-owned
Serco, Secta Group and Quo Health. Some of these outfits have
never run hospitals before. The others have never run hospitals
like those of the NHS which are at least 10 times the size of
a typical private hospital.
The most controversial element is the
creation of independent public-interest corporations with 'Foundation
status'. These organizations will have NHS assets transferred
to their ownership and be granted a licence to operate by an independent
regulator. The proposals were drawn up in consultation with the
private operators, including the chief executive of Kaiser Permanente,
the giant Californian healthcare company.
The Foundation Trusts will be freed from
NHS controls - they'll no longer be accountable to the Health
Secretary but to a locally elected board. They are prohibited
from selling their core assets. But they are allowed to raise
funds for new building from capital markets and to set up joint
ventures with the private sector. All public hospitals are now
to be run along business lines - although there will be no shareholders
Free from NHS control, hospitals will
be able to break with national bargaining arrangements and negotiate
or impose their own pay scales and conditions of service. The
end result will be widening gaps in pay and working conditions.
There will be increasing pressure to generate
new sources of income. NHS hospitals already do this by opening
private beds, leasing out parts of their land or allowing companies
to run on-site services. For example, National Car Parks runs
hospital car parking. Capita and Serco provide visitor and staff
catering. McDonalds and WH Smith operate in hospital lobbies.
Patient Line supplies telephones and televisions at astronomical
rates. This will now be expanded.
New legislation allows hospitals to create
companies which can exploit for research tissue samples taken
during surgery. With ownership of human tissue unclear under British
law, genetic data is a valuable commodity that many biotech companies
would love to own.
At the same time the Government has introduced
legislation to 'redefine' some NHS care. For example, an elderly
or infirm patient may be fit for discharge but still have health
and care needs - washing, dressing or feeding. This used to be
called 'nursing' - but it can now be redefined as 'personal care'
and is no longer covered by state funding.
If local authorities don't pick up the
tab then patients can be billed. The costs and risks of continued
care will pass to the individual, especially the elderly, who
account for around 50 per cent of all hospital admissions. The
fundamental principle of universal services, free at the point
of delivery, will be undermined.
The Government has also established new
regulatory bodies to smooth the way for privatization. The Independent
Regulator has the power to determine the range of services and
treatments to be provided by the NHS, which assets it can retain
and which can be sold. The Commission for Healthcare Audit and
Inspection (CHAI) polices performance standards. CHAI is the direct
route to private sector control. It undertakes reports on quality
in hospitals, success in which can lead to the 'earned autonomies'
of a Foundation Trust - basically entrepreneurial freedoms which
uncouple the hospital from the NHS. The next step is to be forcibly
subjected to new management and franchised to the private sector.
With this new regulatory regime the future of the NHS will no
longer be a state responsibility.
The Government says its doesn't matter
who provides healthcare services as long as they're state-funded.
'Reforms' are sold to the public as improving efficiency and choice
and 'changing the delivery system'. The system will continue to
be funded through taxation.
But a delivery system based on profits
and returns to shareholders fragments the ability to pool the
risks and costs of care from healthy to sick and from wealthy
to poor. It introduces new inefficiencies and transaction costs
making universal healthcare unsustainable.
The inherent but unstated logic of the
NHS Plan is that the privatesector 'partners' will take over the
running of hospitals in all but name. There will be a gradual
reduction in free, tax-paid services at the point of use. Profits
will compete with needs and, as the British experience with railway
privatization and long-term care shows, access to services and
quality is sacrificed.
There is no country in the world that
delivers comprehensive, equitable healthcare through the market
and on the back of for-profit providers. Yet governments across
the world are rushing to follow the British path and are dismantling
their healthcare systems. They and their citizens are in for a
shock. When the market comes to health, access to care will be
a lottery decided at the local level. The fear and uncertainty
of the past are set to reappear.
Allyson Pollock is Head of the Public
Health Policy Unit at University College London and Director of
Research & Development at UCL Hospitals NHS Trust. She is
also Chair of the Society for Social Medicine.