The NHS is, as I went into in a previous post a highly efficient service. It is much loved (see for instance (#welovethenhs on twitter or the Olympic Opening Ceremony). That isn’t to say it’s a perfect service, and there were definitely some challenges facing the NHS even before the government introduced the Health and Social Care Act 2012 (opposed by the BMA almost from the outset, with the Royal College of Nursing, the Royal College of Midwives, and the Royal College of General Practitioners all becoming opposed after things clarified).
There are major challenges ahead for the NHS, and for every other healthcare system in the world. And even without “help” they would be pretty big ones. Some of the main ones are below:
1: An ageing population. You spend more on healthcare for the elderly than the young. Period. And this is only going to get worse.
2: Medical development. Much is now curable. But cures are expensive, especially modern high tech ones. A robot to assist surgery can run to a million pounds – and there was no equivalent when the NHS was set up.
3: Pharmaceutical companies. Partly costs are increasing as a subset of medical research and development, partly as Ben Goldacre extensively documents pharmaceutical research is incredibly corrupt. And of the two screens parallel imports are still there but NICE has been stripped of its powers.
4: PFI. Hideously expensive and a bad idea almost from the start. Private Finance Initiatives is the main cause behind first the creation of South London Healthcare (to merge three near-bankrupt trusts into one), then its recent bankruptcy. Note that as of writing it is likely that the recommendations will involve closing Lewisham A&E (Lewisham being the nearest hospital) which is going to spread the financial mess all round the reason.
These problems were already there without the help of the current government (other than the stripping NICE of its powers). And would be more than enough of a challenge for almost any service, all causing costs to escalate rapidly. Other than PFI, all these are problems facing almost every comparable service in the world. It’s a challenge, undoubtedly. It’s a ship trying to pass between the Scylla of not providing adequate care and the Chrybdis of getting monstrously bloated spending – the last thing it needs is to have someone start launching torpedoes at it.
A common answer to challenges is that “We must do something. This is something. Therefore we should do this.” But what “this” does in the case of the Health and Social Care Bill is drops at least half a dozen torpedoes into the water. I’d spotted several even before hearing John Lister on the subject last week, but really hadn’t worked out the Any Qualified Provider issues.
This isn’t meant to criticise GPs in general or the ones who will end up implementing this set of changes. But they are trained as doctors, not administrators. Different skillset. They are merely the people who will end up carrying the can. But without further ado, the issues from the Health and Social Care bill include:
1: De-skilling. The Primary Care Trusts (PCTs) work. Not always perfectly, but they more or less know what they are doing. The GP Consortia need to build the whole structure up almost from scratch – and reinvent the PCTs while losing expertise.
2: Isolating risks. At present the NHS is responsible for the UK. Care Commissioning Groups (CCGs) are only responsible for their own area of patients, and there is nothing saying they have to work together. It’s like dividing the number of people in an insurance scheme by 300 or so. Much higher risk.
3: Isolating negotiations. At present when an NHS provider negotiates with its local PCTs, that negotiation is binding on all PCTs. Keeps things much fairer, restricts the postcode lottery, and lowers administrative overheads because everyone should receive the same care for any given condition. This not necessarily being binding is a vast administrative overhead and Postcode lottery. (The CCGs can decide to team up but they no longer have to).
4: Destroying oversight. Unlike the PCTs the Strategic Health Authorities (SHAs) are being destroyed and not replaced. And their job is oversight – few can watch themselves truly effectively, and PCTs are huge organisations. The SHAs are imperfect and don’t catch everything but their role is needed.
5: Forcing everyone to become Foundation Trusts by April 2014. Foundation Trusts have a purpose. Freeing high performing and specialist centres from standard oversight (instead they are overseen by Monitor). And even Monitor think there are too many foundation trusts. Foundation Trusts tend to get better performance than standard hospitals but if they hadn’t been performing well they wouldn’t have become Foundation Trusts. Monitor itself says that it shouldn’t have allowed a number of the Foundation Trusts we already have to become Foundation Trusts.
6: Raising the cap on private work at Foundation Trusts to 49%. Remember that’s meant to be all hospitals. Private work has higher administrative overheads than state work and is inherently far more bureaucratic; you need to deal with multiple possible payers. Also it messes up streamlined pathways – but hospitals will not only want to do it but almost be forced to because of the higher profit margins. That’s 49% private care possible at all hospitals. Almost the definition of a two tier health system. (Of course this will mean that private work takes place in a hospital that can cope if it goes wrong – at present if something goes wrong in private care the NHS sorts it out).
7: Any Qualified Provider. At least this is slightly improved from the initial draft of “Any Willing Provider” so setting qualifications is possible. But this doesn’t come with a strict definition of qualified providers, so e.g. Virgin can bid to run A&E (as they do in Croydon). If trains don’t go all the way, that’s one thing. But if A&E doesn’t, that gets bloody. Any bunch of clowns can bid for services (and as is normal with the private sector in Britain, hand all their failures off to the NHS). This not means that we might again put healthcare provision in the hands of people who will trouser the money and run (Croydoc) or again put on only one Out of Hours GP for the whole of Cornwall (Serco), you can plan better if you know what’s coming. So hospital overheads are going to increase due to the risk of not getting activity. And without definitions as to what counts as qualified, there’s a vast junket train possible for companies to have themselves classed as “qualified”.
There are almost certainly more torpedoes in the water. Those are just the ones I’m aware of that are the responsibility of this one bill. And these changes aren’t easily reversible.