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NHS White Paper:

No to the Privatisation of the NHS! Safeguard Its Future! Health Care Is a Right!

Workers' Daily Internet Edition: Article Index :

NHS White Paper:
No to the Privatisation of the NHS! Safeguard Its Future! Health Care Is a Right!

Staked Out for the Vultures- John Lister

Commentaries on the NHS White Paper

Defending the NHS against Privatisation: John Lister talks to London Progressive Journal

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NHS White Paper:

No to the Privatisation of the NHS! Safeguard Its Future! Health Care Is a Right!

Health Secretary Andrew Lansley launched the government’s White Paper on the NHS on July 12. The White Paper sets out plans in which the government intends to build on the model of purchaser/provider which is based on the capital-centred thinking that health care is a commodity and those in need of health care are consumers. On the contrary, health care is a right in a modern society, and the claims of the people for a modern standard of health care must be met. Furthermore, the White Paper aims to give unbridled scope to those monopolies who are digging their claws into the health service to make the maximum capitalist profit. This is the meaning of what some are referring to as the "market-driven" NHS.

The government intends to transform acute hospitals into "social enterprises", which is the tried and tested half way house to privatisation and also make Trusts able to expand their private patient networks and let those that "fail" to "go to the wall". The "commissioning" of health care is in theory being taken away from PCTs, which are to be cut back, and handed over to consortia of GPs. Having had the PCTs turned into "world class" commissioners by New Labour, now the private sector is to be given an even greater rein. In practice, as the GPs will have neither the time nor the expertise to run these consortia, they will be forced to hand this over to the multinational giants who already are taking a stranglehold over the NHS. Billions of pounds will be siphoned off by these health-care monopolies.

In addition, a wedge is being driven between doctors and other health-care professionals such as consultants who are being excluded from the commissioning process and from a say. It goes without saying, that the patients will be powerless to decide on the health care system that they desire. In fact, this is the "freedom" touted by the Con-Dem coalition, which is predicated on a consumer being given "choice" between those monopolies eager to exploit them. In other words, the human being who demands health care as a right is being excluded from a say in theory and in practice in the exercise of this right, and the whole health service is being made less accountable to society and the responsibility of government as the representative of society to satisfy the needs of the people for health care and other social programmes is being denied.

The Con-Dem government is acting on behalf of these US and European health monopolies. They proudly proclaim that "hospitals are to be moved out of the NHS to create a ‘vibrant’ industry of social enterprises under the proposals". This means that under the proposals by 2013 all the hospital Trusts are to become Foundation Trusts, "free" to set their own targets, their own pay and conditions, and take their own numbers of private patients. If under this "freedom" they "fail", then the hospital is "free" to go to the wall. This is set to intensify the already acute instability facing all sections of the health service. It will intensify the pressure for cuts in health care provision, reward those monopolies that can suck the maximum social wealth from the people, and it will intensify the pressure on all health care workers. The pressure on these workers and professionals is already immense, and they are under threat of disciplinary action up to and including being sacked all the time, and are being made the scapegoat for an inhuman system.

To safeguard the future of the NHS, this whole direction must be changed. The resistance of all sections of society is growing, but this resistance is not simply one of opposing the latest proposals. Particularly since the advent of New Labour in 1997, the policy of the ruling elite has been to consolidate the market model of the NHS and use the provision of health care to pay the rich. This was the significance of New Labour’s "Public-Private Partnership" which openly became the Private Finance Initiative. They have left a funding system stacked massively in favour of the private sector. Imposed budgets on hospitals have resulted in "overspending" as hospitals accept patients over the guidelines for activity levels. Meanwhile, the private sector will continue to reap their 100% tariff for all patients.

The just demand of the people is that health care is provided at the highest standard as of right. The fight to safeguard the future of the NHS is part of the struggle to open the path for the progress of society as a whole and end the retrogression being imposed on society by the ruling elite with their capital-centred thinking and programmes. Under the conditions of the ever-deepening crisis of the present system, these programmes are causing disaster for the people.

Health Care Is a Right!
No to the Privatisation of the NHS!
Safeguard Its Future!

Article Index

Staked Out for the Vultures

John Lister*, Morning Star, Wednesday 14 July 2010

The new coalition government white paper Liberating the NHS could reduce the National Health Service in England from one of Europe's largest single employers, with around 1 million staff, to near zero by the time of the next general election.

Tens of thousands would face redundancy through wholesale cuts in "bureaucracy" or lose their jobs through so-called "efficiency savings."

Hundreds of thousands more could find themselves effectively privatised and transferred to non-NHS employers in the biggest shake-up ever to hit this popular public service.

The NHS itself, which currently spends £105 billion, will remain in name only as a "brand," transformed from a major public service into little more than a central fund drawn from general taxation.

This cash mountain would be used to commission a variety of services delivered by non-NHS organisations in a competitive health-care "market" in which a growing number of private providers, including multinational corporations, would be encouraged to operate.

Continued central funding would ensure that patients would mostly not be required to pay for services at point of use, preserving the illusion of continuity of the NHS, while even more non-profit and profit-seeking providers slice off lucrative portions from the public budget.

At present the NHS is divided internally into three sectors.

* "Commissioners" of services operate locally through 152 primary care trusts and 10 strategic health authorities. These hold or allocate budgets for the various sectors of health care.

* "Providers," a network of local NHS trusts covering acute, mental health, community care and ambulance services, together with local community services agencies

* 129 free-standing NHS foundation trusts. These work outside the main NHS management structure and are accountable to an independent regulator, Monitor.

The majority of staff working in all these organisations are NHS employees, enjoying nationally negotiated pay scales and terms and conditions including sick pay and pension entitlements.

In addition around 60,000 family doctors, general practitioners (GPs), work largely as independent contractors to primary are trusts, delivering primary care to a defined list of patients. They work with teams of nursing and other staff, some of whom are employed directly by the GP practice and some through PCTs.

Several years of efforts by the new Labour government have failed so far to persuade more than a small minority of GPs to take on the responsibility of "practice-based commissioning," in which they would shape the policies and spending decisions of their local primary care trust.

The new white paper would completely reorganise this structure. The "commissioning" bodies (PCTs and SHAs) are to be scrapped altogether with the loss of tens of thousands of managerial and administrative jobs.

The public health function of PCTs is to be hived off to local government and the Department of Health itself would be reduced to a small rump organisation.

The commissioning role is instead to be taken over by GPs, who will be obliged to participate, working through local consortia of GPs and, if necessary, forcibly incorporated into a consortium.

It is clear that these consortia would need to enlist substantial additional expertise and administrative assistance, either from former PCT or SHA staff or from private-sector management consultants who in many PCTs have been playing an increasingly influential role for some time.

But while NHS employment among commissioners is set for near-extinction by 2013, the providers too will increasingly be forced out of the NHS.

Foundation trusts, already detached from the mainstream NHS, are to be pushed even further by the white paper proposals to become "social enterprises."

They would be encouraged to set their own pay scales and lift restrictions so they could expand provision of private medicine and their links with the for-profit private sector, "regulated the same way as any other providers."

Health Secretary Andrew Lansley is also known to favour shifting foundation trusts "off balance sheet" from the NHS and allowing them to run as normal companies, regulated by Monitor.

This raises the prospect that new staff recruited to foundation trusts would be employed outside the NHS, its pensions and terms and conditions. Existing staff would initially have their terms and conditions protected, but there is little doubt that growing numbers of trusts would soon set about changing these contracts.

There is no escape for NHS employees. The white paper stipulates that all remaining NHS trusts are either to become foundation trusts, or be taken over by foundation trusts, by 2013, when their current legal status will be repealed.

Community health and primary care services, currently run at "arm's length" from PCTs, would also be systematically put out to tender and either reorganised as "social enterprises" outside the NHS, taken over by foundation trusts or by "any willing provider," whether for-profit or not.

This would be imposed on staff from above. We already know that virtually every sector of the workforce that has been allowed to vote on whether or not to join in a social enterprise has voted by 90 per cent or more to reject the idea. The hostility to private companies would be even greater.

All of these moves to whittle down the NHS to a bare minimum handful of employees will also take place in the context of the fastest and largest spending cuts in history.

Lansley's white paper makes clear that the £20 billion target for "efficiency savings" is to be achieved by 2014, two years earlier than previously planned.

Such a massive and unprecedented squeeze on spending could only be carried through by axing tens of thousands of staff, closing beds, wards and hospitals, and massively increasing the workload of the staff remaining.

However, it's by no means certain that things will go the way Lansley expects. His apparent master stroke of handing commissioning to GPs is itself highly controversial even within the government.

The Treasury in particular attempted to prevent the plan to hand £70 billion in commissioning budgets to GPs with no managerial or commissioning training or experience.

The department's fear is that GPs in many areas will take the line of least resistance, avoiding making unpopular cuts and closures which might antagonise their own patients - making it almost impossible for cutbacks to hit the £20 billion target.

In addition the previous track record of GP commissioning, when the previous Tory government imposed the controversial system of "GP Fundholding" in the early 1990s, was that many GPs did precisely that.

Under that system GPs held back £1 for every £6 they were allocated for patient care, leaving millions unspent. Administrative costs elsewhere in the NHS were forced sharply upwards, with an estimated £500m of additional bureaucracy as each trust was obliged to negotiate one by one with a variety of fundholding practices.

And even the new white paper admits that under fundholding the varying priorities from one GP practice to another brought a "postcode lottery" for patients, with widely varying access to health-care.

Despite this, the system is set be made even more arbitrary by the scrapping of any form of planning, along with many performance targets and any incentive to co-operate, collaborate and share best practice.

Now, as then, the apparent power given to GPs is being backed up with a blunt threat that they have to drive the cuts and rationalisation and stay within financial limits, warning that any GPs or providers that go bust will be allowed to fail in a ruthless, competitive marketplace.

On top of this threatened workload is the introduction of patient "choice," backed up by voluminous information which will no doubt delight some of the sharp-elbowed middle classes, but will confuse and irritate many other less confident and articulate patients. Most just want to be able to access good quality care from their local NHS provider.

But it is far from clear that GPs, even if they want to, would have the time to work through the exhaustive process of offering each patient this choice of not only which hospital or provider to use but which consultant to see, let alone provide detailed studies to back it.

In London and elsewhere the pressure for "efficiencies" in primary care has been for GPs to spend less time, not more with each patient. The white paper makes this almost impossible to achieve.

Will GPs be persuaded to take on this work, which ministers have made clear would not be rewarded by any extra pay? The British Medical Association has waged a strong campaign against a market in health-care, but with GPs themselves divided on the issue it is not clear how it will respond.

The other big question is how strongly the TUC health unions will resist this root and branch attack on the jobs, pay and conditions of their members and the dismemberment of the NHS as a public service, which builds on all the worst aspects of Labour's "reforms."

One thing is clear. If the white paper is carried through, the new system will eviscerate the NHS, wiping out much if not all public-sector provision, and installing the untrammelled competitive market in place of any form of planning, co-operation or collaboration.

It will offer a bonanza for private providers and ring the death knell for any serious attempts to implement policies aimed at reducing inequalities in health.

It can and must be stopped.

* John Lister is information director of Health Emergency.

Article Index

Commentaries on the NHS White Paper:

NHS reforms: Is Andrew Lansley's brutal surgery really needed?

Denis Campbell, The Observer, Sunday 18 July 2010

How does the Great British Public view the NHS? With appreciation, sentimentality, no little pride and recognition that not everything it does can always be great, but that many things are? Or is it with anger and deep frustration – at targets, a lack of choice and faceless bureaucrats allegedly obstructing clever doctors who always know best – and, from that, a deeply held desire to change it utterly?

The evidence – from surveys of patient opinion and experience, both by the NHS and others – suggests that, broadly speaking, most people are pretty happy with it most of the time. Yet Andrew Lansley, the health secretary, last week outlined plans for a major upheaval of the service in England that are clearly motivated by both intense unhappiness with the NHS in its current form and a belief that it needs emancipation from the dead hand of tickbox-obsessed penpushers. Hence the subtitle of the health white paper – "Equity and Excellence: Liberating the NHS". Lansley, it would appear, is its self-styled freedom fighter.

Politicians can't stop themselves from tinkering with the NHS. This is either the eighth or ninth "reform" of an institution that is one of the few remaining expressions of pan-UK identity. No wonder many who work in the NHS, especially at a high level, feel dizzy – and resentful – at the state of near-permanent revolution, and wish it would stop.

No chance. This time Lansley has certainly prescribed truly radical surgery for the supposedly ailing patient. The 152 primary care trusts (PCTs), which currently commission and pay for care for patients, are being scrapped, as are the 10 strategic health authorities. Between them, they employ 64,000 people. Patients will have much more information on who provides good and bad care, and will be encouraged to exercise enhanced choice to go wherever has the highest standards. Poorly performing hospitals, even if they are much loved by their local community, will be allowed to wither away. Competition rules, OK?

Instead of the current system, in which PCTs help decide what treatment a patient should have and where, in future England's 35,000 GPs will do that and become the most important people in the NHS. Instead of each GP surgery being given a budget to employ people – doctors, practice nurses and receptionists – and run its premises, the partner-GPs who run it will be handed a multi-million-pound budget with which to pay hospitals for treating their patients.

If Lansley drives through his plan, patients may not notice that many changes – apart from, with luck, the clinical outcomes closer to the norms in the rest of Europe that Lansley wants to see. The nation's doctors, never easy opponents, have yet to give a considered view of having big changes to their jobs forced upon them by Whitehall, and tension is likely over the private sector's inevitable role, extra money to implement the new set-up and, possibly, demands for more pay for complying. But make no mistake: the changes will dramatically reduce, possibly irrevocably, the state's control over the NHS and the NHS's control over those who actually care for us. That is a long way from both Nye Bevan's guiding principles, and the Tories' pre-election pledges to have no more "top-down reorganisations". As last week wore on, the more people pondered the white paper, from either the right or the left, the more holes they found in it. Dr John Marks, a past chairman of the British Medical Association, quoting Caius Petronius, warned that the revamp could end up "creating the illusion of progress, while producing confusion, inefficiency and demoralisation". On Friday both the Lancet and British Medical Journal published editorials that were unusually critical. Lansley may take all that as the death-rattle of the vested interests.

It may prove to be something else altogether: the start of a coalition of concern that blocks reforms that have precious little evidence to commend them. It is a brave politician who takes liberties with a national treasure – or a reckless one.

We cannot allow the end of the NHS in all but name

Seumas Milne, guardian.co.uk, Wednesday 14 July 2010

When it comes to spin and honeyed words, the Cameron-Clegg show is already putting Tony Blair and Peter Mandelson in the shade. However extreme or cockeyed the policy, from savage benefit cuts for the poorest to the chaotic scrapping of school building projects, a gentle gloss or a winning apology from a coalition frontman and critics go weak at the knees. But this time they have outdone themselves.

Under the banner of Liberating the NHS, the health secretary Andrew Lansley this week unveiled a programme of dramatic change, promising to free the English health service from bureaucracy, put family doctors in the driving seat and hand power to patients. What could be more appealing to a workforce and users fed up with bureaucratic directives and corporate managerialism?

In reality, Lansley's health white paper opens the door to the comprehensive privatisation of healthcare and the end of the NHS as a national service. If the plans are taken to their logical conclusion, by 2015 the NHS will be little more than a brand. From a major public service with a million employees, it will have become a central fund with a minimal workforce, commissioning services from a string of private companies in a fully-fledged healthcare market.

"The bottom line of this is the abolition of the NHS," Dr David Price of Edinburgh University argues. "It will remove the government's duty to provide a universal healthcare service." His colleague, Professor Allyson Pollock, believes it will lead to "full privatisation". Andy Burnham, who did Lansley's job until May, calls it the "dismantling of all public accountability and national standards in the NHS".

The scale of what is being proposed has yet to sink in. By handing control of the bulk of NHS funds to England's 35,000 GPs to buy healthcare, the government hopes to divide the medical profession – who have mostly opposed privatisation – and appeal to patients, who feel more at home with local doctors than health trust bureaucracies.

But self-employed GPs will be forced to form consortiums, which are then expected to be run by the private firms that chafed at the last government's slowness in opening up the "commissioning market" to unconstrained profit-making. No wonder Kingsley Manning of the health firm Tribal is looking forward to the "denationalisation of healthcare services in England".

Meanwhile, all hospital trusts are to be turned into freestanding businesses outside the NHS. They will be allowed to go bust or taken over, encouraged to form "partnerships" with profit-making private companies and obliged to remove all limits on private provison. These new, independent trusts are supposed to be not-for-profit "social enterprises", but health policy experts scoff at the distinction when profits can be distributed as "surpluses" or extravagant salaries to directors.

Why should anyone worry who provides healthcare? Because the weight of evidence is that private markets in health bring exorbitant administrative costs, lead to cherrypicking of more profitable patients, increase inequity and the postcode lottery gap, generate conflicts of interest, are unaccountable, and increase pressure for top-up payments and "care package" limits.

The scandalous costs of creeping privatisation are already clear enough, from PFI projects to independent treatment centres. This year the Commons health select committee found administration costs had risen from 6% to 14% by 2005 as a result. They're certainly higher now – and are double that in the US, by some estimates. But now the coalition wants to put the NHS in the hands of the very health corporations that fought Barack Obama to a standstill over his attempt to bring universal health coverage to the US.

No wonder the government is already ditching patient rights over GP and hospital appointments, and David Cameron was dithering yesterday about whether to maintain the right for cancer patients to see a specialist within a fortnight. The prime minister also struggled to explain why this upheaval in the NHS would avoid the increased costs that has attended every other reform.

No doubt he hopes to slash pay for NHS staff who end up being employed by the new foundation trusts or private companies. But the whole plan reeks of a triumph of ideology over common sense and public opinion. Only two months ago, the coalition parties solemnly pledged no more "top-down reorganisations of the NHS", and elections to primary care trusts. Both promises have been scrapped (the trusts will be abolished), while the Lib Dems have been given the sop of local government control of public health, about to be engulfed in spending cuts.

But of course this isn't just about the Conservatives and the Lib Dems. New Labour laid the ground for everything the coalition is planning to do to the NHS – as with privately controlled academy schools and its abortive attempt to privatise Royal Mail. The market structures, foundation trusts, even the insertion of US corporations into commissioning and GP consortiums were all products of the Blairite version of "public service reform".

In fact, Lansley's scheme to dismantle the health service is what Tony Blair himself yearned to do, if only he hadn't faced the "block on reform" next door. As Mandelson spells out in his memoirs, it was Gordon Brown's foot-dragging on foundation hospitals and tuition fees that gave Blair the excuse to renege on his promise to resign before the 2005 election. But privatisation continued under Brown's premiership, if at a slower pace.

The result is that Labour opposition to the assault on the NHS is hamstrung by its own record. With the exception of Diane Abbott, none of the candidates in the leadership election has yet come out for an alternative to privatisation – even though both Wales and Scotland have successfully turned their backs on it. David Miliband lauds Blair's reforms, while in the battle for Labour's London mayoral nomination, Oona King has as good as defended postal privatisation.

That will have to change if the dismemberment of Britain's most important social institution, backed by a corporate lobby that has its claws in public life, is to be prevented. It will need many others, of course, including Lib Dems, doctors and other health professionals, trade unionists and patients groups – even Tories. But it's a fight we all depend on.

White paper signals more NHS privatisation and less stability

Unison, 12/07/2010

UNISON, the UK’s largest public service union, today slammed health plans set out in the government white paper saying they will plunge the NHS into chaos.

Karen Jennings, UNISON Head of Health, said:

"Far from liberating the NHS, these proposals will tie it up in knots for years to come – they are a recipe for more privatisation and less stability.

"NHS staff will feel badly let down by plans to undermine national pay bargaining.

In a race to do this, the Government wants employers to lead negotiations on new contracts resulting in a two-tier workforce within Trusts and anomalies across the NHS.

"If the NHS is to be more efficient it needs to have stability. People in fear of their jobs, or how they are going to be able to deliver services, cannot be expected to make informed or rational decisions. This is no way to take patients or staff with you.

"There are just too many contradictions e.g. cutting back on bureaucracy and doing away with PCTs and SHAs, but allowing the proliferation of GP consortia.

"Handing over £80bn to untried, untested and probably private sector led consortia, is reckless. How will they be held accountable for that money?

"Accelerating the approval of Foundation Trusts means that managers will be concentrating on the business of preparing for that, rather than on patient care.

We must learn the lessons from recent disasters such as Mid Staffs. "UNISON will be seeking every opportunity to respond to the white paper in a thorough and thoughtful manner.

"We will be collaborating and co-operating with other like-minded organisations to challenge its most damaging aspects."

Response to The NHS White Paper

NHS Support Federation, 12 July 2010

Responding to today's publication of the NHS white paper, the health pressure group, NHS Support Federation, accused the government of favouring commercial business over patients and cast doubt on plans to save money by restructuring.

Federation director Paul Evans said:

"Patient power will be overwhelmed by the influence of unaccountable companies. No matter what individual patients want, profit-motivated firms will now have a huge say in what care is available and much of the fairness, value and public trust in the traditional NHS will be lost."

"GP commissioning will create a spaghetti-like snarl of conflicting interests, where profit will inevitably come before patients. Paying companies to spend the huge NHS budget on other companies is a recipe for scandalous waste and the sort of shady deals that the public must be protected from."

"Savings from sacking local NHS managers are unlikely to be as large as the government predict, due to redundancy costs and extra GP payments. Few GPs have the skills or the time to do this essential job and the plan to use the private sector will be expensive and sacrifice public control."

NHS shakeup: Private companies see potential to expand their role

Denis Campbell, health correspondent guardian.co.uk, Monday 12 July 2010

Private companies believe the shake-up of the NHS will lead to a big expansion of their currently small role, as many GPs will need their help to carry out their new role as commissioners of healthcare.

Firms which already have small-scale involvement with family doctors are preparing to exploit the chance to gain an unprecedented foothold in the NHS once GPs start spending £80bn of NHS funds.

They said they expected the switch to GP commissioning outlined in the white paper to help them have a much wider involvement with the NHS, and especially to work closely with the 300-500 new "consortiums" of GPs which the Department of Health expects to emerge to become key purchasers of treatment for patients.

Bart Johnson, chief executive of Assura Medical, said: "We are enthusiastic about the reforms. Assura Medical already works with groups of GPs across the country providing a whole range of services. We see this as a good opportunity to build upon our current work with GPs and the NHS to improve health outcomes for patients."

Kingsley Manning, business development director at Tribal, which also already provides commissioning support services to some parts of the NHS, cautiously welcomed moves which the firm said "could lead to the denationalisation of healthcare services in England".

Manning, a visiting professor at the management school at Imperial College London, added: "There is a significant opportunity to improve commissioning in the NHS. We can help because we make the investment in the technology and skills needed to save the NHS money. We have done so with many primary care trusts [PCTs], saving millions."

Bupa Health Dialog, a subsidiary of the global health giant's UK arm which specialises in extending the firm's relationship with the NHS, also expects to gain work. "We would say that the new policy represents a significant opportunity for us to work with more and more GPs, and GP organisations, to improve outcomes and quality [of care] for patients", said the subsidiary's managing director, Bob Darin. A "significant" number of GPs "will want to work with Bupa or companies like us to provide tools to help them take a holistic view of their local population's clinical needs and thus make more informed commissioning decisions".

Doctors' leaders and health experts agree that GPs' clinical skills will not be enough for them to discharge their new responsibilities and that the consortiums will need help them with finance, management, accountancy and data analysis.

Nick Goodwin, a senior fellow at the King's Fund health think-tank, said: "It's likely that many of the GP consortia will need to either hook up with a PCT or go outside the NHS to firms like Tribal, United Healthcare or Bupa Health Dialog. Most PCTs don't have the expertise to offer technical skills, like information systems that allow them to understand the health needs of their local population."

But the British Medical Association, the doctors' trade union, voiced alarm at the likely expansion of private firms' role and said that most GPs would aim to perform their expanded role without them. "The BMA position on this is that we would not be happy [for private sector involvement]. We don't think it is necessary", said Dr Laurence Buckman, chairman of the BMA's influential GPs committee.

"I think the vast majority of GPs will not be keen to involve the private sector in this. This is an opportunity for GPs to unite to make sure that the health service works well for the people of England, without the involvement of the private sector," he added. The issue could lead to tension between the BMA and the Department of Health in forthcoming negotiations about implementation of the planned changes.

A BMA spokesman added: "We are concerned that increased private competition within the NHS could lead to wasteful expenditure or the duplication of services, for example independent sector treatment centres providing the same services as as the NHS, when that money could be spent on frontline patient services.

"We have always said that the private sector is no more efficient than the NHS and a lot of money is being wasted on private sector contracts and companies . We feel the involvement to date of private sector companies hasn't delivered many benefits to patients or the NHS. It's much better if you have services wholly provided by the NHS. The private sector should be the provider of last resort.".

He cited the possibility of management consultants coming in to do jobs currently done by NHS staff. "We would be very concerned about that," he said.

The health secretary's message that independent operators are welcome to carry out work for the NHS rips up attempts by Labour's health secretary, Andy Burnham, to establish the health service as "the preferred provider" of NHS services.

David Fleming, national officer for health with the Unite trade union, denounced GP commissioning as "an untested, expensive Trojan Horse in political dogma that will give private companies an even greater stake in the NHS – this way of operating has already happened in the USA."

The NHS Support Federation, an independent campaign group, said GP commissioning "will create a spaghetti-like snarl of conflicting interests, where profit will inevitably come before patients. Paying companies to spend the huge NHS budget on other companies is a recipe for scandalous waste and the sort of shady deals that the public must be protected from," said the group's director, Paul Evans.

Article Index

Defending the NHS against Privatisation: John Lister talks to London Progressive Journal

Tomasz Pierscionek, July 9, 2010

TP: Can I begin by asking you a little about the origins and roles of London Health Emergency (LHE). I understand LHE was established in the autumn of 1983 as a collective umbrella organisation for local campaigns defending hospitals, in the capital, against closure. Could you elaborate a little about the reasons for why LHE was founded and what its primary aims were?

JL: Following the election in June 1983, in the aftermath of the Falklands war, the Thatcher government increased its parliamentary majority. In July of that year, Nigel Lawson, then Chancellor, put forward a new budget which included a 1% overall cut in NHS funding. The NHS had already been experiencing financial difficulties and this 1% cut to the NHS budget triggered a round of cutbacks and closures for about two dozen hospitals in London.

Each of the cutbacks or closures was resisted by local campaigns. This was the political heyday of the Greater London Council and a number of the local campaigns got together and decided to put in a bid to the GLC to fund a London wide campaign group. A sum of money was liberated to fund London Health Emergency. The funding was sufficient for three fulltime workers, an office and a publicity budget.

I was brought in to be the publicity officer of LHE in April 1984. Early anger against the cutbacks merged into a big fight against the privatisation of hospital services. In my first week as publicity officer, there was major discussion at the LHE steering committee over the strike that was at that time taking place at Barking hospital in East London in protest at the privatisation of cleaning services.

Was this strike successful?

No, but it was a very large strike that lasted 18 months. It was probably the biggest of the national battles against privatisation and it became a landmark dispute. The strikers became known everywhere and it really symbolised that fact that a challenge was being put down to the unions to mount a massive campaign against privatisation, or the process of privatisation would take place bit by bit locally because there was not enough strength to resist each onslaught of privatisation at the local level.

The Barking strikers were very courageous. Several hundred female cleaners took part and most of them stood solid for 18 months. In the end they became convinced that the national union leaders were not going to support them and so the strike died away. However, there were also several successful strikes across the country, including one that took place in a mental health hospital in Oxford where the privatisation agenda was defeated.

The website of LHE describes the group as being the country's largest and longest-running pressure group in defence of the NHS. We have discussed the formation of and the challenges faced by LHE in the early-mid 80s. How have the challenges you faced changed over the past 20 years?

I think the biggest change has been in the climate of the trade union movement. The defeat of the miners’ strike caused a period of 25 years in which the labour movement has been very much on the defensive, fearing the repeat of a national dispute on that level. This has had an impact at local level. In the early 80s, there was a strong shop stewards movement and they set a lead for the NHS. There was a whole group of activists in the NHS in 1982 and 1983, having become active around the time of the pay dispute of 1982.

This was the first-ever (and only) national pay dispute which saw simultaneous action by nurses and health professionals as well as ancillary (non-clinical support) staff, who had previously been the main backbone of trade unionism in the hospital sector. The dispute went on for the best part of a year because the union leaders were very reluctant to call for national action. However, a layer of activism was generated amongst nurses and other NHS staff who had not previously been well organised in a trade union sense. This meant that for a while there was quite a strong left wing attitude within the NHS. There were four separate health unions at the time (NUPE, COHSE, ASTMS and NALGO). The national leadership were in general reluctant to drive forward militant action or to link up local struggles: but each of these four unions had local and regional structures through which in some areas members could express more militant demands, and from time to time individual unions could be pressed into taking more concerted action.

If one of these unions took action, there would almost be a competition between the other unions to ‘catch up’ and do the same so as not to be seen to be falling behind. It was a healthy competition in a way. Members could lobby their own union to follow suit.

Nowadays, Unite is a large union in which health is a very small component. UNISON is the main health union and many people who are now in UNISON weren’t in any of the original health unions. Within UNISON and Unite, it is very difficult to take action at local level if no such feeling exists at leadership level.

Do you think it is harder these days for action to come from a grassroots level?

Well, as I mentioned, morale took a battering, following the miners’ strike. It had a big impact on the unions, at all levels. I would be critical, especially in recent years, of some of the national leaders of the health unions for not giving clear enough direction to their members. At the same time, the leaders can turn around and say that too few of the grassroots union members are demanding action at local level. To some extent they are right: there is a real problem with a lack of activism.

Additionally, seven to eight years ago, there was a restructuring of pay in the NHS. This involved most of the local branches of the main unions spending a huge amount of time in joint committees with managers sorting out very technical matters such as grading and job evaluations. The unions have become consumed with such procedural matters. Rather than adopting a ‘bigger picture’ view of the NHS as a service that relates to the public, they have tended to take a much more introspective view, focusing, for example, on issues relating to union membership and other branch matters. There has also been a mushrooming of individual level "casework" involving representations of members one by one: some of this has been driven by grasping lawyers and unions’ fears of possible litigation.

All of this type of work detracts from traditional, collective methods of union organisation and the mobilisation of members to take action themselves to improve their conditions. As such, some of the stronger union braches have become depoliticised and deactivated.

Taking the results of the recent election into account, what do you think the public can expect from a Con-Dem coalition in terms of healthcare and which areas of the NHS could suffer on account of the coalition’s policies?

Well, the first thing coming down the line is cuts. These will be known as efficiency savings. In one of Andrew Lansley’s first statements as Secretary of State for Health, he commented that Labour had not planned to make sufficiently large efficiency savings whereas his party would be ready to make such savings.

Bear in mind that the efficiency savings calculated by the NHS nationally at the end of last year projected that over the next 5 years, the NHS would be facing a funding shortfall of around £20 billion. The rising costs of dealing with an increasingly elderly population, new treatments and more expensive medicines are thought to account for this gap.

NHS London (the Strategic Health Authority that oversees the health of the capital’s 7.5 million inhabitants and has a £13.5 billion budget) has said that in order to bridge the funding gap, they need to consider closing a third of London’s hospital beds within the next 4-5 years. This is an absolutely unprecedented scale of cutbacks the likes of which have never happened in the NHS before.

It is also interesting to note that whilst the Tories ran an election campaign hinting that they were going to ‘ringfence’ the NHS and bring about above inflation increases in NHS spending, the Lib Dems were actually more radical in proposing cuts. Vince Cable MP (current Business Secretary) attacked the Tory economic formula, argued for larger cuts and, saying that it would not be sustainable to protect the NHS whilst making big cuts in public services.

The two parties in coalition also agreed to oppose what Labour had proposed in the run up to the election, namely the policy that for services which are to be contracted out, the NHS should be regarded as the ‘preferred provider’. This meant that until options to improve NHS services had been completely exhausted, these services should not be offered out to contract to the private sector or to social enterprises.

This caused a huge furore among some of the past and present members of the Labour cabinet, such as the previous Health Secretary Alan Milburn, and amongst some of the Labour Party’s advisors, who complained that this policy would impede free competition and would prevent healthy competition which they claimed was required to drive up standards. Here, I am talking particularly about Primary Care Trust services (which cover primary care and most community-based services), which employ about 250,000 staff and account for a large section of the entire NHS budget, around 11% or £11-12 billion a year. The New Labour government had (unwisely in our view) decided that these services, which had been provided by Primary Care Trusts, should be broken away from these trusts and managed separately, divided up again and then offered out to various competitive tenders to create a local market in these services.

The Lib Dems have been advocating competition on the basis of price. For me this really brings back memories of the privatisation of hospital cleaning and support services, back in the 1980s, a consequence of which was increased rates of MRSA. The idea that somehow ‘any willing provider’ can now bid for and take control of NHS services is a serious cause of concern. There is a real determination to force through privatisation, almost as a point of principle, despite the lack of evidence that it is in the interest of patient care.

Let’s discuss the impact these changes to the NHS will have on the staff. I understand that as part of the process of cutbacks being proposed, retiring NHS staff will not be replaced. What will be the implications for the remaining NHS staff? Will they be forced to work in a more stressful environment, having to face a greater workload, an increase in managerial bullying and having to cope with other pressures, such as a lack of beds resulting from over demand on the system?

Undoubtedly, all of the above. Also, add to that the £1 billion-plus immediate cut in local government spending, plus further cuts in the 22nd June budget and the consequences of the freeze in next year’s council tax – all of which are likely to squeeze social services after years of brutal cuts and tightening "eligibility criteria" to exclude all but the most completely frail and infirm from any social service support.

The local government plays a role in relation to health by providing social services and other support which is crucial to discharging patients from hospital and ensuring continuing care outside of hospital. In other words, we have a two pronged attack here- a squeeze on social services which help to look after the frail and elderly in the community. At the same time, we face a squeeze on frontline hospital services.

In addition to this there will also be the implementation of a tariff: limiting the number of patients that hospitals can treat, with a strict cap being put on the number of elective patients that can be referred to hospital. Hospitals that exceed this cap will face a penalty as they will only be paid 30% of the standard NHS tariff payment for each patient treated. We will be facing an all round squeeze on hospital services.

Further to this, older and more experienced staff will likely be the first to leave the NHS, leaving a diminished number of remaining staff left to carry the can without the possibility of bringing in agency staff or recruiting more staff to fill the gap. You can see how stress in the workplace could rapidly increase.

Consider too, the impact on mental health services. Mental health cuts never seem to attract the same headlines as cuts to other services. As such, mental health will be seen a soft touch; an area where cuts can be pushed through with minimal repercussions, as far as the politicians are concerned.

TP: There seems to have been a big expansion in PFI contracts (Private Finance Initiative), in recent years. What is the reason behind this?

JL: Well, PFI never happened under the Tories. The Tories devised the policy but they were never prepared to go as far as New Labour to placate the private sector and allow them to sign these deals with no risk to them whatsoever. The only piece of legislation New Labour passed in 1997 that pertained to the NHS, was a short Act: the National Health Service (Private Finance) Act 1997 which stipulated that in any PFI scheme that went broke, the debt would be picked up by the Secretary of State for Health.

There has been an escalation in the number of PFI schemes set up. The only thing that seems to have stopped this is the sub-prime mortgage crisis.

The sub-prime mortgage crisis undermined the key insurers that used to provide further risk avoidance for the private sector. The insurers in the US lost their credit ratings and so were unable to offer insurance for these schemes any longer. As you may be aware, presently PFI schemes account for £11 billion pounds worth of the NHS and these schemes are set to cost the NHS a massive £62 billion over the lifetime of their signed contracts.

So these private contracts cost the NHS a lot more than their true value?

Oh yes, massively more. PFI costs the NHS a lot more than if it were to just borrow a straight mortgage for the same amount of money.

There are many additional downsides to PFI. There is the alienation of staff from their own building. For example they are not allowed to put an eyechart on the wall. There is also a demoralising effect on staff. They are told from day one, in no uncertain terms, that the hospital is not their building, it belongs to a private consortium.

You will generally find that PFI hospitals have a reduced number of beds, compared with the hospitals they replace, and as such are relatively small compared to the local level of demand.

PFI schemes seem to have come to a natural end at the moment. Even the Tories have begun to be critical of their cost. The problem is that, under the new government, this means there will be no new hospitals built as the government won’t be putting in any extra money. One of the difficulties in campaigning against PFI was that you appeared to be the awkward individual opposed to the building of a new hospital. This was not the case, of course. We simply argued that if a new hospital needed to be built there were plenty of cheaper ways to pay for it than signing a contract with a private company.

For the benefit of our readers, could you please explain a little about how Social Enterprises work and the rationale behind them?

The theory behind them is that they are non-profit businesses. In other words, they allow the workers (of frontline services) to work together in an autonomous unit, outside of the bureaucracy and red tape of NHS management and structures, and able therefore to ‘innovate’ and ‘improve services’ without having to wait for all kinds of bureaucratic processes. That is the theory. They will obviously have to bring in a surplus every year, as that is part of the way in which they function. The surplus would not be delivered to shareholders. In every other respect, the process would run like a business.

A major criticism is that it is very hard to see anything working as a co-operative, in a progressive sense, if the very foundations of the process are being pushed through by ‘little Hitler’ managers with no regards for the actual views and wishes of the staff they allegedly represent. The people who are exercising what Lord Darzi called the ‘right to request’ for the formation of social enterprise are, in every case that I have come across so far, senior managers who detect a personal interest in having the freedom to, for example, set their own pay scales. The controls would still be in their hands and they would try to drag the whole organisation behind them. Wherever staff have been balloted, 80-90% have been against the concept of Social Enterprise. They are concerned that outside of the NHS, they would lose their NHS pensions and payscales, as well as their NHS status, career structures and training opportunities, etc.

I understand that the idea behind ‘Foundation Hospitals’ is to give hospitals more autonomy over how they spend their money and to reward hospitals that do well whilst penalising those that perform poorly. That sounds very much like a free-market approach to healthcare. It seems unfair as a hospital situated in a deprived area will face greater pressures on its services. A hospital situated in a deprived area will be serving a population with different, and possibly greater health needs, than a hospital situated within an affluent area. Can you comment?

We have an example from not long ago. The hospital and primary care trusts within four of the six boroughs of South-East London had very large deficits. At the same time, in the two remaining boroughs of south-east London, there were two Foundation trusts who between them were sitting on surpluses equal to the deficits of the remaining trusts within the area. Being Foundation Trusts, they were under no obligation to share their surpluses or to participate in any way in helping to resolve the problems found elsewhere in the NHS. It really is an ‘I’m alright Jack’ type of approach to running the NHS. Far from developing the collaboration and co-operation in these matters, it actually carves up the NHS into a competitive market.

What can the public and NHS staff do to campaign against cuts and the encroachment of the private sector?

In terms of the break up and privatisation of primary care services, or Transforming Community Services as it is known, people need to know it is happening. Much of this occurs in relative secrecy, without any proper consultation. The privatisations implemented thus far, were done without any public consultation. We need to be able to ‘smoke out’ where it is happening locally and reveal the scale of it, the significance of the services under threat and the role these threatened services play in the community. Once local people realise this and once NHS staff realise that people are willing to support them, there should be a lot of resistance.

The public have more scope to fight against the privatisation of their community services than most of them realise, and at the same time, less knowledge of how to fight this than most campaigners realise. The key thing for campaigners, such as politicians and trade unions opposed to the privatisation of community services, is for them to make sure they disseminate the information they have into the public domain.

For example, back in the 1980s, when we were fighting against the privatisation of hospital cleaning services, LHE discovered, to our horror, that the Trade Unions were only issuing material relating to the impact of privatisation on wages of health workers. At that stage, they had little to say about what the consequences of privatisation would be on the hospital services themselves and the patients using them. Conversely, most members of the public viewed the issue the other way around. Though they may have been sympathetic towards healthcare workers, for them the main question was whether or not they would have a cleaner hospital. We had to fill the gap, spelling out how privatisation undermined standards of patient care and put the whole of the public at risk, not just the health workers whose jobs, wages and working conditions were under attack.

In the run up to the General Election, all three major parties preached the need to make cutbacks to public spending and hence public services. Can you propose an alternative solution to that advocated by the political mainstream?

I would start by actually proposing three different cutbacks, which I believe would be a step in the right direction. First of all, I would sack all of the management consultants running rampant through the NHS. At the last estimate I recall, they cost the NHS about £500 million a year. Quite a significant contribution could be made just by cutting back on these people who seem to have contributed little or nothing of value for the huge investment that has been made in them. Furthermore, damage done to the NHS could be reversed. Not least in the fact that a lot of the relatively well paid managers in the NHS who employ the management consultants seem to have abdicated much of their decision making responsibility and avoided thinking for themselves, relying on management consultants to fulfil this role. It’s like hiring the organ-grinder, but getting fobbed off with his monkey.

The second thing, I would do is to renegotiate PFI. The issue of PFI needs to be revisited in order to bring down some of the enormous costs of the scheme. These deals were all negotiated with interest rates of upwards of 5-7% in years past when they were much higher. Nowadays the government can borrow at a much lower rate, around 0.5%. It is ridiculous for the costs of PFI to still be so steep, especially so as a couple of the major banks involved in PFI are now owned by the taxpayer. We’ve gone and bought the banks and we are now paying out to those banks, and will be doing for as much as the next 30 years for some of these PFI schemes. UNISON for example, have called for the nationalising of PFI, which isn’t necessarily all that radical a policy. We’ve already nationalised the banks, so why not PFI?

The third thing is that there is a whole layer of additional bureaucracy in the NHS, centred around what is known as ‘world class commissioning’. In many areas of the NHS, a whole raft of what are called ‘commercial directors’ were recruited. The NHS ran for nearly 60 years without the need for a single commercial director and now we have them all over the place. They don’t bring anything of any benefit to the NHS whatsoever. The whole ‘world class commissioning’ idea has been an entire waste of time and money. Anyone directly employed in this matter should either be sacked or given some sort of useful job somewhere in the NHS that could actually benefit patient care.

Those are three cuts and between them well over a billion pounds could be saved each year.

On a wider level, the PCS (Public and Commercial Services trade union) has been making the point that the government has been sacking tax collectors, sacking the very people who are supposed to be gathering the money that is to be spent on running public services.

Each tax collector on average generates £600,000 a year for the Inland Revenue. By cutting back on the number of tax collectors, this has resulted in a large gap in taxes not being collected because key people are not being asked to pay and many who are evading payment are not being actively pursued. This process should be reversed. Rather than allegedly trying to streamline the civil services, as the previous government claimed to be doing- attacking the people who collect this money to pay for public services- we should do the opposite and recruit more of these people.

Mark Serwotka, general secretary of the PCS, made that point that if current levels of taxes were collected properly, you wouldn’t even need to increase taxes by a large amount to bridge the public spending gap that we now face.

So at times bureaucracy could save money?

Bureaucracy isn’t necessarily a bad thing if it means that there are officials who know what they are doing and systems that allow them to work well. If this means that we need people to go out and bang on some doors and collect taxes from some rich people who are not paying, then why don’t we do just that?

Instead of the Daily Mail foaming at the mouth at a handful of social service ‘skivers’ or illegal immigrants, who they claim are the problem, why don’t we have a little bit more anger about the extremely wealthy who are evading paying their fair share of tax.

In fact, what we have at the moment are government owned banks employing a whole handful of people who go out and advise industry on how they can avoid paying tax. Lloyds TB and other banks have divisions of advisors whose job it is to advise wealthy people on how to pay less tax. This is all paid for by us. We are paying the government to pay the banks to employ people to go out and advise the rich on ways of paying less tax and hence create a bigger gap in the money available for government spending. How mad is that!

Indeed, not that’s not the kind of story you read in the pages of the mainstream media. I understand that a few years ago you published a book titled: ‘Health Policy reform. Driving the wrong way.’

That was five years ago. The book was looking at the spread of market style policies- the type of policies that I object to being carried out in the UK- and examining the extent to which they were being promoted around the world.

I am talking particularly about the developing world and how organisations such as the World Bank and USAID are able to shape government policy by deciding whether or not countries are deemed to be credit worthy. They can decide whether or not to issue loans. The World Bank is committed to the idea of the contract culture rather than public service culture, preferring the expansion of the private sector rather than having government run public services.

About 18 months ago, some research was conducted by Professor Chris Ham of Birmingham University, who once advised Tony Blair on matters of health. Professor Ham’s research investigated the extent to which the model of ‘commissioning’ healthcare could be shown to work on a global scale. He went around the world picking out examples, similar to those used in my book, and he came to the same conclusion which is that there is no evidence anywhere that Healthcare Commissioning actually works.

Through examining different healthcare systems around the world, have you come across one that seems to have found an optimum way of doing things.

At the point that I wrote this book, in 2005, I would probably have mentioned the Scandinavian model. The sad thing is that we have had a rash of right wing governments in Scandinavia who have begun to adopt similar policies to those of the New Labour government.

What they did in Denmark was to create unattainable targets for an underfunded public sector to reduce waiting times. When these targets couldn’t be met, the argument was made that private sector providers needed to become involved, paid for from public budgets. This is just like the UK, where an artificial expansion of the private sector has been achieved not through its growth in a free market but through the use of government patronage and public funds (NHS budgets) to ensure guaranteed profits.

So sadly, the countries I would have been pointing to in many ways as a model of satisfactory and relatively democratic healthcare are not necessarily still a good model.

I believe you’ve written a book more recently.

Yes, it’s called ‘The NHS after 60- For Patients or Profit.’ It came out in 2008 for the 60th anniversary of the NHS. The book charts the history of the NHS since 1948 with the heaviest focus being on the last 20-30 years. A few years ago, I started doing some teaching sessions on health policy at Coventry University. I used to be able to cover the whole history of the NHS in a 90 minute lecture. Now I cannot even cover the last 10 years within an hour and a half because there have been so many rapid changes which are of great significance.

Between 1948-1978, the model was pretty much intact and when a Tory government in 1961 was persuaded by Enoch Powell, to build a new generation of hospitals across the country, nobody even thought about using private finance.

Margaret Thatcher started to really change things in the 1980s and brought the notion of markets into the ideological debate. We fought against Thatcher’s market reforms, calling it a slippery road to privatisation: but Margaret Thatcher never privatised a fraction as much as Tony Blair. Now Blair’s market is likely to be a launchpad for more privatisation.

Dr John Lister is the Information Director of London Health Emergency (LHE). Founded in the autumn of 1983, LHE is the country's biggest and longest-running pressure group in defence of the NHS.

Dr Lister is also an Associate Senior Lecturer in Health Journalism at Coventry University and is the author of numerous publications on the topic of health policy. His latest book The NHS after 60: for patients or profits? was published in 2008.

Dr Tomasz Pierscionek is a junior doctor working in the North East of England. He is co-editor of the London Progressive Journal and has recently become a board member of the global health charity Medact.

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