The BBC, now officially the unofficial news station for the Conservative party, came a cropper over the weekend when Hugh Squim, the oleaginous health editor for Broadcasting British Conservatism, reported that a leaked draft NHS white paper proposing radical changes to the NHS ‘would see a reduced role for the private sector’, when in fact it says nothing of the sort. Squim subsequently re-wrote the offending paragraph after being hand-bagged on twitter by the redoubtable Prof P, but the episode only goes to show how sloppy the BBC news reporting has become. It is the BBC’s job to give us unbiased fact based news, not our job to correct it’s shoddy reporting with the true facts. What can we glean from the leaked draft?
The first hurdle to be overcome is the writing style, which is that of a brainwashed second rate intern with a buzz word fetish. The draft shows exemplary inclusivity and diversity: all last year’s words are there, from organisational silos to collaborative working in an agile framework, all threaded on a turgid syntax, up with which we should not have to put. This is further padded out with a lot of sanctimonious hogwash about learning lessons from how well the NHS responded to the coronavirus pandemic. This fatuous clappery, like the Thursday evening ritual last spring, rather ignores the fact that much of the response, which ranged from pretty much shutting down elective care, to dumping any patient fit enough to be strapped to a trolley on a beleaguered care sector, not to mention the Department of Health and Social Care’s hideous frenzy to blow billions on failed contracts with the private sector, hardly covered the NHS, let alone the Department, in shining glory.
That much at least is history. What does the draft white paper have to say about the future? On a first reading, once one has managed an agile exit from the organised silo of Whitehall hogwash, several themes emerge, none of them encouraging. The big one is a move to integrated care, which this post will cover, but there are significant others that will have to wait for another day. These include, among other things, a power grab by ministers (‘we want to strengthen the Secretary of State’s powers of intervention, oversight and direction [over NHS England, a new merged over-arching body]’), plans to create a charter for coercive healthism (‘care that focuses not just on treating particular conditions, but also on lifestyles, on healthy behaviours and prevention’), and, alongside that, plans to encourage an orgy of data sharing (‘[we] will set out a range of proposals to address cultural, behavioural and legislative barriers to data sharing’ that will in time allow care to be ‘informed by a better data drive…identifying those who are at risk and who we can impact…’). Cripes.
But, for now, back to integrated care. It sounds like a wonderful thing, but it is in fact a euphemism for managed care, a heinously rigid form of healthcare delivery much favoured by that country notorious for its outrageously expensive yet remarkably ineffective healthcare, given the enormous outlay, the United States of America. OECD data repeatedly shows America as the highest per capita spending on healthcare country in the world (play around with the sliders on the OECD chart to get the historical picture), and yet its health outcomes, measured by current life expectancy both at birth and at age 65, is mediocre, and on both measures is worse than the United Kingdom (again, Dr No recommends playing around with the settings and sliders on the OECD charts to get the full picture).
A fundamental problem with American healthcare is that it is largely private, and so is as largely concerned with the profit motive as it is with providing healthcare; and healthcare does not work well when it has to serve two masters. Many decades ago, we in the United Kingdom had the good sense to realise that the only sensible way to fund and run a health service is to have a publicly owned and provided service paid for out of taxation. Most, but not all, with America the standout exception, developed countries have come to much the same conclusion, albeit in many cases with a bastardised private-public healthcare system.
Managed care, on the other hand, as developed and implemented in the United States, is a for-profit insurance based system, with the ‘managed’ care, provided by so called health maintenance organisations, or HMOs, a crude but, as the OECD data shows, failed attempt to contain costs. But at the same time, ‘management’ rigorously controls what can and can’t be done by individual doctors; and so, in the land of the free, they find themselves paying more for less. Choice, that evil chimera in the land of healthcare, is an illusion for most Americans; instead, it is the invisible hand not of the market, but of the accountant, that decides what treatment they will or will not get.
The draft white paper, if it becomes law, will set up a similar management structure here. It will do away with CCGs (the GP based system for commissioning healthcare) and all the competitive purchaser provider split paraphernalia, and replace the whole lot with ‘integrated care systems’. We want, says the draft white paper, ‘to legislate for every part of England to be covered by an integrated care system (ICS)’. There is much waffle about duties to collaborate — about as hopeful as locking two tom cats in a room and ordering them to collaborate — but make no mistake, these ‘integrated care systems’ are boilerplate HMOs, to be imposed on the NHS. If the draft white paper ever makes it into law, then we too, like America, will have managed care, rigorously and tightly controlled by HMOs dressed as integrated care systems.
Far from ‘seeing a reduced role for the private sector’, the private sector will have direct access to the NHS, unfettered by tiresome competition rules. ‘We anticipate that there will continue to be an important role for voluntary and independent sector providers,’ the draft says, ‘but we want to ensure that where there is no value is running a competitive procurement process that services can be arranged with the most appropriate provider’. No need to bother with all that competition nonsense round here. Instead, private interests will become partners, not only let in through the back door as services are ‘arranged with the most appropriate provider’, but also welcomed with open arms at the front door, as members of new ICS Health and Care Partnerships, with members drawn from a wide range of ‘partner organisations’ including ‘voluntary and independent sector partners’, and ‘tasked with promoting partnership arrangements’. Or, to put that partnership word salad into plain English, the private sector will have a seat at the NHS table where it can promote its own interests.
If all this seems fanciful, recall what has happened over the last year. NHS contacts worth billions of pounds of tax payers money have been awarded without competitive tender to private concerns. Then the draft white paper starts to make a whole lot more sense: it is merely the first draft of a bill to enact what has already started to take place.