How the Government will fuck up the NHS | Centralisation not privatisation is the problem

The Government has announced it’s new plans for NHS reform, the draft of which was leaked a week or 2 ago. Fuck is a strong word for a headline, but I am afraid that’s what is about to happen.

The Lansley reforms of the NHS will be reversed, along with almost all of the internal market, leaving the NHS structurally close to how it was under Harold Wilson, but with a stronger relationship between the NHS and Local Authorities. Decades of health policy going back to Thatcher are being swept away.

This is all very good news, and one of the likely outcomes will be a big fall in the outsourcing of patient care to the private sector. It is a much. more radical restructure than Labour were planning.

Personally I don’t mind the private sector bidding to provide services to the NHS as long as:

  1. they invest their own capital, which is at risk, in return for a financial rewards
  2. the costs of awarding the contract is proportionate to the value of the contract

The problem with the Lansley reforms was that a private sector company could take over an NHS service which the state had already invested capital in, and run it for a profit without risking any of their own investment. This isn’t capitalism – it’s private companies feeding off the state.

The second problem – the cost of awarding contracts – has been endemic in the NHS for decades. In most years since the NHS internal market was introduced by Margaret Thatcher the costs of managing the internal market has been greater than the value of the contracts outsourced to the private sector. Successive pro-market reforms have failed to entice the private sector to become big players in UK healthcare, while the Lansley reforms active drove US companies out of the UK.

Scrapping all of this is very good news, even if it is slightly odd to see Matt Hancock announcing a big reduction in the bureaucracy which his own party had dumped on the NHS.

So why fucked?

There is a massive downside to these reforms – a huge power grab by Whitehall and Ministers who will be taking direct control over the NHS.

Historically there has been a split between Ministers and the Department of Health, which deal with policy and standards, and the NHS, which delivers healthcare services. The NHS is operationally independent of Ministers and Whitehall, who hold it to account for performance. The Lansley Act attempted to remove the Secretary of State’s accountability for healthcare. The new reforms puts that accountability back, but at the expense of giving Ministers and Whitehall operational power over healthcare services.

The importance of this can be seen in the response to Covid. The NHS and Local Authorities have performed incredibly well, which is why the vaccine programme is such a success, and why we haven’t seen our hospitals over-run like Italy despite having more cases.

In contrast the response of Department of Health has been crap. Everything that DH has run has been shocking. Track and Trace. PPE. The app. Everything has been dreadful, and everything has been outsourced to mates of theirs.

That is exactly why allowing DH operational control over the NHS is a bad idea. They don’t have the skills, and they are not set up to have this competency. Whats worse is that they are a soft touch for mates of theirs in the private sector who will promise the moon on a stick and deliver a load of rubbish. That’s why DH currently cant find over a billion items of PPE that they have paid for.

The NHS is world class at managing healthcare. Incompetent, neurotic, micro-managing Ministers aren’t.

The mess of cronyism that will ensue from this jumble is different from privatisation of healthcare services that the left are worried about, but will be just as damaging to public finances. Private sector companies won’t have to invest and risk capital in return for their profits – they will simply need to be mates with Ministers.

There is absolutely no reason for this centralisation other than the obsession that the Government has with control and power. The guiding principle of the Johnson Government is this: the rich can do what they like, the rest of us can do what we are told. Controlling the lives of ordinary people is central to their worldview. Just look at the threat of 10 years in Prison for breaking quarantine rules; a government that fails and then threatens its’ own citizens with jail for it’s own failures. An operationally independent NHS can have it’s own voice and it’s own view on funding and priorities. That is about to end.

The real issue facing the NHS is’t privatisation. It’s staff.

The NHS exists not because of politicians but because it commands the support of clinicians. Without their engagement there is no NHS. The successes of the response to Covid were clinically led, not Ministerially.

The existential threat facing the NHS is staffing. It has become a worse place to work over the last decade, and pretty much every part of the service is understaffed. Covid has left the remaining staff exhausted and burnt out. Clinical leadership has been replaced by dictat.

This is the issue that needs fixing. And neurotic micro-management by Ministers will make this worse. If it’s not fixed there is no NHS.

https://www.theguardian.com/politics/2021/feb/06/boris-johnson-planning-nhs-england-overhaul-leaked-paper-shows

https://www.bmj.com/content/362/bmj.k3007

https://www.healthpolicyinsight.com/?q=node/1699

https://www.gov.uk/government/news/blueprint-launched-for-nhs-and-social-care-reform-following-pandemic

Postscript 1

One of the themes I have returned to on NHS reform is the way that the left have focussed on privatisation of hospital services, and the threat of US companies taking over and imposing an American style model. Over the past few years there has been a big fall in the privatisation of patient care, not an increase.

This was never remotely likely to happen, but the left campaigned against it none the less. While it was doing this it completely missed the 2 big stories – centralisation, and staffing.

It is worth reminding ourselves that attention seeking middle class lefties spent lots of money attempting to stop the internal market being dismantled for reasons that were always a muddle:

https://www.bmj.com/content/362/bmj.k3007

Postscript 2

I have been covering the slow demise of the NHS internal market, and the decline of outsourcing over the last few years. You can read more here:

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