Coalition Health Policy - end of NHS?

Is Coalition health policy, as in the Health and Social Care Act 2012, the end of the NHS as we have known it?

Launching discussion about the end of the NHS as “we have known it” implies a political discourse; the NHS must “represent/mean” something for it to end. On its inception in 1948, the core founding principles and values of the NHS are that it has been, and should be, a health care system funded and provided by general taxation and should be free at the point of use (Hunter, 2008). Thus, we can succumb to the conclusion that the end of the NHS would mean the end of a predominantly tax based system incorporating user fees. However, those are the founding principles from 1948 – the NHS as “we have known it” also exposes the idea that our generation value the NHS in its own context. Furthermore, investigation appears to start in the 1990s.

A main feature of the Health and Social Care Act of 2012 is the move from Primary Care Trusts to Clinical Commissioning Groups. The Kings Fund (2012) argues that “the idea of commissioning as a discrete function within the NHS dates from 1991”. The NHS Community Care Act 1990 effectively introduced a level of competition in the market creating a split between ‘purchasers’ and ‘providers’ in local health authorities; an act which established itself well into the 90s, and one that New Labour chose to alter rather than abolish. New Labour launched Primary Care Trusts (PCTs) in April 2000 (NHS Confederation, 2011) with three initial objectives: i) to purchase care for local communities, ii) to directly provide services such as community care, and iii) to work with local agencies to tackle health inequalities and improve public health. PCTs later expanded and work involved much more than that, but their role was evident from the outset: competition to create marketization. And so what can be drawn from this then is how market forces have been playing a force in health care, notably general practitioning, since the early 90s, cementing under New Labour during the next decade.

As previously mentioned, the coalition government introduced Clinical Commissioning Groups (CCGs) under the Health and Social Care Act 2012. These replaced PCTs and in a simple form would be GP consortia, taking over all the commissioning functions of the NHS. As Naylor et al (2013) discusses, the new CCGs control approximately two-thirds of the NHS budget, with a GPs duty to commission the majority of NHS services to their patients. This means that GPs, in their CCGs, act as both purchaser and provider; they purchase and provide for patients. The belief is that CCGs will improve healthcare because GPs are in a better position than managers when it comes to making decisions over the services patients need. The implications of this are simple and easy in the sense that this creates competition and a marketization of health care, representing a move away from the traditional setting of Bevan’s 1948 NHS, through to Thatcher’s managerialism in the 1980s (Lart, 2012). A key feature of the 1948 NHS Act was central control of hospitals; the aim was to “nationalise” the capital stock of the health service, with local authorities still running community services. Quasi-market structures represent an “evolutionary” change, and the debate on this issue is centred on the end of Bevan’s “central control” of delivering a national service both as purchasers and providers. Fundamentally, this has consequences for the analytical discussion as to whether the Health and Social Care Act of 2012 means the end to the NHS as we have known it. It can be argued that in turn, a new phenomenon of marketization is occurring within health care in the UK, yet these ideas and policies have been around since the 1990s. And so the NHS as we have known it naturally must mean we have known it as a competitive system because our generation have not “known” the NHS from before the 90s. Therefore, the Health and Social Care Act of 2012, with a shift from PCTs to CCGs, cannot be seen as the end to the NHS, as the system has looked the way it does now for over two decades.

The Health and Social Care Act of 2012 reformations were laid out in the July 2010 White Paper “Liberating the NHS” (Lart, 2013). The term “liberating” immediately signals some form of reformation, and with the changes planned, it naturally raised debate regarding whether the value and ethos of the NHS were taken into account. First of all, the background to the act is important. During the 2010 election campaign, health policy was not taken as seriously as other issues; Cameron had his own personal reasons for defending the NHS (Watt, 2009), inferring a commitment to keep it free at the point of use, as well as stating intentions to increase health expenditure in line with inflation. Additionally, Andrew Lansley, the then shadow secretary of state for health, had already outlined his intention to move away from PCTs and put more responsibility on to the shoulders of GPs (Campbell, 2010). During the build up to the 2010 general election though, health and social care took more of a back foot compared to the bigger issues such as immigration, with the Telegraph (2010) reporting education, employment and the economy as more pressing matters. All parties displayed assurance to not forget the founding principles of the NHS, with the bigger evolutionary changes discreetly lined up. It can be argued that the coalition’s Health and Social Care Act 2012 unsettled many, but it can also be argued that debate has arisen out of the sheer fact that some were not expecting such a drastic change, resulting in the statement that it is the end of the NHS as we have known it. The debate appears to be much more to do with empirical discussion against rational thinking; the NHS in effect hasn’t changed that much in the last 20 years to justify the argument that the coalition is ending it. Rationality has been displaced for empirical arguments – what the NHS “represents” is slowly being eroded and the future ultimately looks “pessimistic”.

One clear example of this is in another of the major changes that the coalition government took in reforming the NHS operative. As part of the 2012 Act, Lansley aimed to make trusts more autonomous; all NHS trusts were to become Foundation Trusts (Nuffield Trust 2013). The state, instead of owning, would become more of a regulator. The coalition did this through allowing hospitals to generate more of their profit from private patients, as reported by the BMJ, “NHS hospitals in England will be able to increase the proportion of money they can earn from private patients to 49% from 1 October 2012” (Kmietowicz, 2012). The figure 49% is a vital statistic as it symbolizes much more than it lets on: it means that the NHS does not comply with EU Competition Law. On the one hand, this means that a citizen of a member state in the EU cannot “just come over and get their hip replaced in an NHS hospital”. In a more defined manner, the NHS will maintain its status as a healthcare provider for social functions, meaning it will not open itself up to the European market, where an uncertainty kicks in. It indirectly signals an attempt to lack convergence with other members. A rational argument from this is that the coalition is defending the universal aspect of the NHS, capping the income generated by hospitals from private patients at 49%. This is a rational argument as it takes the literal facts on board: the 49% falls below EU competition law of 50% (Pinsent Masons, n.d.). But on the other hand, there is the empirical argument as well. The empirical argument takes a broader picture in that the move towards a greater generated income for hospitals creates an internal market with quasi-market structures, with or without a cap. It puts those who argue that the coalition is destroying the NHS in a strong position as allowing any form of internal market in the NHS puts an end to the desired equitable NHS set up in 1948.

Such a debate is epitomized by Le Grand and Hunter (2013) discussing the bill representing an end to the NHS. Le Grand responds to the empirical argument on the fear of rising competition resulting in an unrecognizable NHS by introducing qualitative data: “colleagues at the London School of Economics found that during the period when patient choice was introduced in England, hospital quality improved fastest in more competitive areas. He later goes on to add that “colleagues at York found competitive reforms even improved equity of service delivery”. Le Grand’s comments are finalised in his response to the debate at hand by arguing the NHS will not end because “large chunks of the NHS are private and have been since 1948, for example, most GPs are in private, profit making partnerships”. The implications for this discussion are obvious in that they literally mean the marketization of the NHS from the 1990s does not mean anything as the private sector has prevailed since its inception in 1948. Nonetheless, my debate focusses upon the end of the NHS “as we know it”, implying that the 2012 Act must in some way be different to how it has been for the last twenty years or so. The immediate answer, as already discussed, is no. But Le Grand makes valid points to counter those that fear the coalition government has brought about the end to the NHS.

The points which Hunter makes in the debate are much more intriguing. Hunter does not argue that this is the end of the NHS, but that the end will begin to happen. More simply, the beginning of the end. He argues that the end will happen because the coalition “replacing publicly run and accountable services with a mixed economy of care largely delivered by for-profit corporation” and “embedding market competition as the driving force for the NHS” will come at detrimental effect. Hunter uses Sweden to make his point. Sweden, traditionally known for their universal principles and able to boast a GINI coefficient of just 0.24 (The Economist, 2012) is suffering from “profit driven health services, which are increasing the inequities in the supply of primary healthcare”. The set-up of the Swedish health care system is similar to that of the United Kingdom (Gallagher and Cruz, 2013). The Health & Medical Services Act 1982 gave county councils considerable freedom in health services, decentralization. It is also worth noting that the foundation of the system is in primary care. This is similar to what Lansley achieved through the 2012 Act by handing more responsibility over to GPs with locally run CCGs. Also, the Swedish health care system is primarily funded through taxes and the role of private health insurance is supplementary. The interpretation of Hunter’s argument goes far beyond fear of competition in that if Sweden, a country based on universalism and equality, is becoming steadily more inequitable in health care services, then it would be easy for a country such as the UK to fall into the same pattern. This is especially the case as the health care system of both countries is strikingly similar. And so, Hunter leads us to the conclusion that instead of the Health and Social Care Act 2012 representing an end to the NHS, it is the beginning of the end because it indicates further privatization in the future, “destroying the public service ethos”. In this instance, the new act introduces much more competition than previously known, inviting a greater presence for private companies, therefore meaning it is the end to the NHS as we have known it.

In conclusion, the question “Is Coalition health policy, as in the Health and Social Care Act 2012, the end of the NHS as we have known it?” should be grappled with in order to be resolved. To fragment the question, the Health and Social Care Act 2012 has been seen in the literature as much more than an alteration to the health care system in the UK. The 2010 White Paper “Liberating the NHS” offers debate in the title alone, with the proposals suggested further offering a political discourse as to how healthcare should be dealt with by the welfare state. The end of the question “end of the NHS as we have known it” corresponds more alternative meanings in that a pivotal to question is “who is we?”. If “we” is taken as the whole of society then the facts are incontrovertible; the Health and Social Care Act 2012 is a further move away from the universal, state-provided NHS introduced in 1948. But this essay has replied to the debate as “we” meaning my own generation, and so it is important to enquire how “we” can see the NHS. In my opinion, we cannot see the NHS as nothing more than it has been since the splitting of purchasers and providers under the NHS Community Care Act 1990. Consequently, the NHS has simply not changed sufficiently since the 90s to merit the end of the NHS by the coalition. In spite of this argument though, I do support Hunter’s argument that the coalition’s health policy is the beginning of the end of the NHS because they intend to spread competition throughout the health care system, demonstrated by the move to allow hospitals to generate 49% of their income from private patients. It cannot be denied that by trying to get more and more patients to pay for their service as well as paying for health care in general taxation will become more popular as it means patients can jump quickly up waiting lists and so forth. It is easier to predict we will move more towards a system of user fees following coalition health policy than a move back towards equity and universalism. Therefore, coalition health policy, as in the Health and Social Care Act 2012, is not the end of the NHS as we have known it; it is potentially the beginning of the end if coalition health policy is allowed to extend.

References

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Gallagher, J., Cruz, M. (2013) Health Policy in other developed countries [Seminar to BSc Social Policy: Healthcare Policies] 30^th October.

Hunter, D. (2008) The Health Debate. University of Bristol: Policy Press.

Kiemtowicz, Z. (2012) ‘Hospitals will be able to earn 49% of their income from private patients from October’ The BMJ, 345(e4823), Highwire Press British Medical Journal Publishing Group [online]. Available at: http://www.bmj.com/content/345/bmj.e4823 (Accessed: 4^th Nov 2013)

Kings Fund (2012) Clinical Commissioning: What can we learn from previous commissioning models? Available at: http://www.kingsfund.org.uk/topics/nhs-reform/white-paper/gp-commissioning (Accessed: 11^th Nov 2013)

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