Dismembering the NHS

Heath secretary Andrew Lansley’s muted apology to nurses – I’m sorry you seem incapable of understanding my reforms – may not be enough to save his career as the Lib Dems demand his head on a pole. But what’s spooking NHS staff far more than Lansley’s apparent inability to get his message across is the breathtaking insensitivity of Monitor’s new chair, ex-McKinsey man David Bennett. In March, Bennett gave an extraordinary interview to The Times, likening the NHS to a utility company. Now he’s trampled over the toes of NHS chief executive David Nicholson by suggesting that the NHS is heading for financial meltdown and many Trusts will have to make far bigger savings than the 4% predicted.

The notion that the NHS is going to be fed to the market and asset-stripped is something Lansley has been very keen to deny but Bennett’s comments are all the more potent because – if the Health and Social Care Bill goes through – Monitor is set to assume enormous power as the economic regulator for both health and adult social care. It will license providers of NHS services in England, regulating prices and promoting competition. So it’s absolutely vital that the Board is led by someone with a deep understanding of the complexities of health and social care, who appreciates how services are closely interwoven and dependent on careful planning and collaboration for survival and patient safety. So possibly not David Bennett.

If your electricity company goes under, you get another one. If you local hospital closes, you don’t. Healthcare has lots of demand but not enough money to pay for the supply. You can’t provide healthcare for all, free at the point of delivery, through competition because some patients – often the ones who put in the least money – are far more expensive and complicated than others. The NHS pools everyone’s risk and money, and the rich pay for the poor. This provides a decent, often excellent but occasionally dreadful service. It needs politicians to butt out, as Lansley is suggesting, but it also needs long-term collaboration, transparency and stability. Appalling failures tend to happen in the NHS with the combination of lack of money and massive structural reform. The Government has unwittingly created the perfect storm for another Bristol or Mid Staffs. Bennett’s promise of dismemberment is very close to the bone.

Bennett was chief policy adviser to Blair who, like Lansley, wanted the NHS to compete on quality not on price. Alas, Blair got sidetracked by opening up the NHS market and offering private companies cheap deals to cherry pick NHS patients, never mind the quality. The word ‘quality’ has featured hundreds of times in every White Paper and Health Bill for fifteen years but the only specialty where we have reliable data that provides comparative benchmarks on quality is adult heart surgery. Labour poured £105 billion into the NHS and yet much of it was wasted because commissioners had no proof of the quality of the care they were buying.

Handing commissioning over to GP consortia isn’t a quick fix to this conundrum. GPs might hear which services are going under by rumour and innuendo, or might favour other services based on personal experience or friendship. But without hard comparative data, you simply can’t commission or compete on quality. Ironically, the one area where we have the least information on quality and value for money is primary care. We think GPs are jolly good people doing a brilliant job in difficult circumstances but we don’t know how much of the care they provide is wasteful or unacceptably poor. So what qualifies GPs to be in charge of commissioning more than anyone else?

The health reforms at least have an outcomes framework, with NICE desperately trying to come up with 150 quality standards to guide commissioning. Once you set the standards, you have to audit services to make sure they’re achieving them and then identify the significant outliers who are killing patients. It takes time, money and good statisticians. So it’ll be several years before anyone can even begin to commission services rationally. By which time – if David Bennett is right – many NHS hospitals will have failed to reach their new 7-10% savings targets and will be on special measures pending takeover by private companies. Lansley’s problem is not that the nurses didn’t understand his reforms but – thanks to Bennett’s alarming candour – they understood them only too well. MD