Make no mistake; these are the biggest reforms to hit the NHS since its inception. By 2015, if the coalition government is successful in implementing its White Paper, the NHS will be an entirely different beast. Since it was founded, it has been a taxpayer-funded, predominantly top-down, health system that provided (nearly) free medical care at the point of need. By 2015, if the timeline is to be believed, this will be true only if you have uncorrected myopia or a burgeoning cognitive impairment.
In a nutshell, the plans involve scrapping the 10 Strategic Health Authorities and 152 Primary Care Trusts and replacing their purchasing function with about 600 local GP Commissioning Consortia. This mild-sounding and jargon-filled sentence disguises a revolution in how healthcare will function in this country, when you also know that Payment by Results will be extended, every secondary care trust will have Foundation status, and there will be Personal Health Budgets for patients and an enshrined right for them to be able to choose where, and by whom, they are treated. And one existing healthcare watchdog, Monitor, will be a new economic regulator for the system.
Let’s break all that NHS-ese down into simple English:
- Patients will be able to choose where to be treated and by whom
- Information on past performance will be made available, to allow a (moderately) informed choice on their part
- Small groups of GPs, based on what their patients request, will buy that treatment from hospitals, or any other other organisations, whether not-for-profit, social enterprise or private business
- The cost of that treatment will come from individual patient personal health budgets rather than massive block contracts for large chunks of the population
- They will only pay the full amount if the hospitals succeed in providing high quality treatment
- The payment system will be regulated by a watchdog
I don’t know about you, but to my eyes, that’s pretty much exactly the same as introducing a free market in healthcare, with a regulating watchdog. In other words, a private healthcare market.
Or, even more punchily, privatisation.
The only difference is that the existing NHS structures are not being sold off. And that’s where the real genius of these proposals comes in. Rather than having a massive and politically-damaging battle on privatising the NHS, the government has simply “privatised” the payment system by empowering patients to choose where to spend their personal budgets. By allowing money to follow individual patients in this way, the NHS will now have to compete against other providers in a real competitive market, stripping it of its state-funded advantage.
If it provides an efficient, cost-effective service, it will get customers (sorry, patients) and GPs will arrange pay for this out of their health budget. If not, the customers will go elsewhere, and so will the money.
This could go horribly wrong if the regulators, watchdogs and performance indicator systems aren’t up to scratch. Or it could succeed beyond its wildest dreams. Whichever, it’s been a change we’ve been building up to for the past 20 years. The vast sums of money the previous Labour government poured into the NHS were the equivalent of putting a critically ill patient on life support. The money’s run out, and life support is no longer an option. It’s now a choice between risky, highly-invasive surgery or the quiet, slow death of the NHS. I’m delighted this government has the guts to try operating.
If it works, we’ll have a vibrant health care industry, with a leaner, more efficient NHS still being by far the biggest provider, and still providing care to all who want it, free at the point of need. The NHS will kept in check by an empowered general public able to spend their personal health budgets as they see fit, even if that means going private and topping up any extra costs beyond their state-funded personal health budget from their own pocket.
Privatisation? If it looks like that, I’m all for it.
It’s an interesting view and I really hope it does work out to reinvigorate and revitalise the NHS. Idealogically, the importance really rests with the ‘free at the point of delivery’ aspect but my cynicism mostly arises from the historically attempts and continued attempts to ‘privatise’ the social care markets which have reduced user choice drastically by relying on larger providers that are able to benefit from economies of scale at the expense of more costly individualised services.
My immediate thoughts and concerns lie not with the ‘empowered general public’ but with those who are live in more marginalised communities or who are less able through social circumstances to advocate well for themselves and that while the majority of younger, more able citizens can benefit from taking their money and choosing, it is more likely to be the deprived areas and those who are not as vocal or as confident who may suffer in the process.
I do hope you are right though. For me, a positive outcome is much more important than ideology.
Thanks for the feedback. I certainly agree that these changes are a huge gamble, and there is a lot of potential for it to go wrong. I guess, fundamentally, I just can’t see the NHS surviving in its current structural format (the money’s run out, we’re very familiar with the excessive bureaucracy and inefficiencies of the system, and it can be very unresponsive to individual patient circumstances).
If that’s true, something has to give and change, and a move towards a more patient-focused system appeals to me. Regarding the worry about it disadvantaging the deprived/less vocal, it’s possible that these changes may actually give them more of a voice. Taking mental health as an example, I think most of us working in and around the field would agree it’s been chronically underfunded for many decades compared to more glamorous (and politically attractive) specialities.
But if GPs can now use their patient’s personal health budgets to decide what services to buy, I think they will be quite minded to invest in mental health. GPs generally get snowed under with “psychiatric-ish” issues, taking up vast quantities of their time. At the moment, if they have someone with, say, depression and need medication advice, they need to make a secondary care referral. Most of the time, that results in a costly outpatient appointment, a letter from the psychiatrist with a bit of advice, and a discharge back to primary care either at that first contact or within a couple of appointments.
How much more cost-efficient, and easier for the patient and the GP, would it be for the practice to have someone at about Associate Specialist psychiatrist level come into the practice once a week or so and “sweep up” all these kind of referrals and filter which truly need full secondary care? Under the new proposal, it becomes much easier for GPs to specifically commission this sort of “intermediary” service between primary and full secondary care.
So a long-suffering, relatively deprived population may actually get faster, better care.
Of course, I may just be being blindly optimistic!
That’s a good point that I hadn’t considered to be honest. I think I have been snowed under a sea of scepticism as it more fitting with my general nature.
As I said before, I want desperately to be hopeful and am absolutely won’t let any possible ideologies get in the way of anything at all that might deliver better services.