Gabriel Scally on the future of our National Health Service

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May 13, 2013 by Protect Our NHS

This is an interview copied from the current edition of the Bristol and Bath paper, The Spark. http://www.thespark.co.uk/. Gabriel Scally is one of the few academics and previous health administrators who is expressing his concerns about the reorganisation of the NHS publicly and very coherently.

What exactly is happening to our NHS?
There is no way to make this simple, but I will try! The recent Bill that set out all the changes in the NHS is around four times the size of the one that originally set up the NHS in 1948. It’s unbelievably complex, which is part of the problem. The golden rule in trying to understand all this is ‘follow the gold’ and look to see who benefits.

Which bill are you referring to?
The Health and Social Care Bill 2010-12, which was passed (after much controversy) and is now an Act of Parliament which will be implemented on April 1 this year.

What is the overall purpose of the Act?
Well, that’s a matter of political opinion. The Coalition would say it is designed to promote patient choice and reduce NHS administration costs. I see it as an attempt to fragment and ultimately demolish the NHS and I think the current climate of financial austerity is being used to pursue a longer- term agenda aimed at dismantling the state. The private sector is taking over provision of NHS services and there’s a steady rolling out of a programme of active privatisation across the country.

Why did you resign from the Department of Health (DH)?
I couldn’t ethically continue to work as a senior civil servant in the DH and be paid to take part in the demolition of the NHS and the public health system. Remember, this government coalition came into power on the back of a promise of ‘no-more top- down reorganisations’, which pleased me because I’d been reorganised seven times already. Not only did this turn out to be false, but also this latest restructuring was unlike any of the previous ones because very few, if any, people could explain to you coherently how the system would work. In the past we could always believe that what we were doing was going to deliver a better NHS and better health for the population. On this occasion it’s not possible for anyone to believe that. I can’t see how the NHSis going to work – and what’s worrying is that perhaps it’s not meant to. I resigned because I’m very alarmed about what’s going on and I wanted the freedom to oppose it (if I was still working for the DH I’d be forbidden from discussing the proposed changes).

So what is the first change we need to know about?
At the moment the NHS is organized into Primary Care Trusts and Strategic Health Authorities. Both of these have been abolished and will disappear at the end of March. From then on there will be one national body: the NHS Commissioning Board. Within that, the NHS will effectively be split into and run by two bodies; Clinical Commissioning Groups and local offices of the Commissioning Board. The Secretary of State for Health will then put all responsibility for anything that goes wrong on the shoulders of the NHS Commissioning Board. This, in effect, means that the NHS is under the control of an unelected, undemocratic body and that there is no effective control through Parliament.

Isn’t getting rid of NHS bureaucracy a good thing?

There’s a lot going on here. On the one hand you have a huge amount of responsibility being handed to the local level, while at the same time their budgets are being cut in real terms. You can’t run the NHS with a smaller civil service in London and a huge numberof local authorities all pulling in different directions. Once Clinical Commissioning Groups assume control in April, there will inevitably be issues of so-called postcode lotteries. It’s a recipe for disaster. When there were local Health Authorities and, later, Primary Care Trusts, they met in public, consisted of local people, and the public knew that they were concentrating on healthcare for the local population.

What is a Clinical Commissioning Group (CCG)?
A CCG is a group of GPs who will be responsible for commissioning nearly all
the services that you need in the NHS. Most of the money – around four out of every five NHS pounds – will now go to GPs to commission services, ie, all the sorts of things GPs would refer you to, such as gynaecology, cancer, paediatrics or whatever, plus community services such as physiotherapy and district nursing etc.

What’s the thinking behind this switch to GP-led commissioning?
The idea is that GPs are very well placed, as front-line doctors, to know exactly what their patients want, and they’ll now be in charge of spending resources and thereby able to give patients in their area what they need.

Why do you think this is a problem?
The majority of GPs don’t want to take over control of the NHS and its funding, and that’s the express view of their leadership, both in the BMA and the Royal College of Practitioners. I trained in general practice and it was no part of my training to be responsible for millions of pounds of NHS money. GPs are justifiably concerned about the extra work and burden being laid upon them. Also, they feel very uncomfortable with the issue of budgeting for hospitalcare being introduced into the consultation process between GP and patient. A patient wants their GP to be ‘on their side’ and to act in their interests but if GPs are responsible for the hospital budget then how do patients know where their GP’s priorities really lie?

You’ve talked about privatisation: how exactly is this happening?

It’s right across the board. The NHS is being atomised into thousands of different, private providers of health services. More and more general practices are being taken over by the private sector, as are some out-of- hours doctors’ services. If you need to go to hospital, you may well find the hospital run by a private sector company whose priority is making profits which go to shareholders abroad. (Hinchingbrooke Hospital in Cambridgeshire, which is run by a private sector company called Circle, is an example).Again, the issue here is the motivation of the organisation and what lies behind clinical decision-making: is it about the best interest of the patient or is it about profit? The absence of a profit motive in the NHS is crucial: it’s an important reassurance to the patients.

Hasn’t the NHS always made use of the private sector?

Yes, when waiting lists got too long, or there was a shortage of capacity. I don’t particularly have an issue with that, as long as the principle holds that the NHS remains in charge of it all. What we are seeing now is the wholesale shift of large parts of the system to the private sector. So it won’t be the NHS occasionally using the private sector as a tool to assist it, it will be the private sector taking over NHS facilities and services. It used to be up to local NHS bodies to decide if the private sector would be invited to tender to provide particular services and that the NHS was the preferred provider. But the new doctrine of ‘Any Qualified Provider’ (AQPs) in effect means that all services will be up for grabs. And grabbed they will be by the private companies.

Other than profit motivation, what else concerns you about privatisation of services?
There are issues about the quality of care. We’ve seen that in Bristol with Winterbourne View, where a private company called Castlebeck stepped in to provide services and provided them extraordinarily badly. The follow-up work after that scandal showed that two thirds of the private sector facilities weren’t meeting basic standards. There are also issues around transparency. These companies are basically not accountable to anyone other than their shareholders.

So who is accountable when things go wrong?

This is what worries me. NHS organisations in the past were all, without exception, accountable to the Secretary of State. Private sector organisations are not. This is a big, important difference. There is, of course, the Care Quality Commission (CQC), which is charged with overseeing standards of care and carrying out inspections, and also there is an organisation being established called Healthwatch. I think they will both have an enormous task. CQC fell down badly in respect of Winterbourne, and with the privatisation of so many services the landscape within which they are going to have to work will be more complicated. I think it will be very difficult for them.

Can the NHS as we know it be ‘saved’?
It is possible to rebuild the NHS but the longer this goes on, and the more radical the changes are, the more difficult it will be to put it back together again. I’m still very actively involved in trying to protect the NHS so that when there is an opportunity to restore it, we can put it back together again. It’s vitally important to oppose these changes over the next two years and support NHS staff and campaign groups who are against privatisation. Make sure your local councillors and MP understand your views, and in the run-up to the next general election, help and support those who are standing on a platform of reversing these changes and giving us back our NHS.

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“That’s the standard technique of privatization: defund, make sure things don’t work, people get angry, you hand it over to private capital.” Noam Chomsky

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