LANSLEY'S DISASTROUS REFORM OF THE NHS

Marjorie Smith

What the Tories propose for the NHS is utter madness that will only guarantee the worst possible outcome. The proposed reforms will act as a Trojan horse for privatisation. Andrew Lansley's proposal that General Practitioners (GPs) in local surgeries have the strategic responsibility of allocating health care outcomes is also ideologically idiotic.

It is the equivalent of giving the petite bourgeoisie ultimate responsibility for the economy. GPs might claim to protect the NHS, but they are the only segment of the state-provided health care system of in the UK that is not fully integrated into the NHS.

It is also highly likely that once Lansley's plan to have groups of GPs' commissioning all health care for patients then the crucial building blocks of privatisation will be in place.

Of all the major health care professionals' representative bodies, it was only the British Medical Association, representing GPs that opted out of being fully part of the NHS. In 1947 they objected to Anuerin Bevan's proposal for universal health care by a margin of 89% to 11% as they saw it as a threat to their position and income.

Most GP surgeries are still private practices that contract their services to the NHS. Most surgeries are run as separate profit centres with the partners taking a share of the profits. They are paid by the NHS according to the number of people they have registered to their practice.

They remain independent contractors to this day. GPs and their representative body the BMA have always been the most reactionary element of health care in the UK.

In response to Bevan's proposals one former Head of the BMA claimed "I have examined the Bill and it looks to me uncommonly like the first step, and a big one, to National Socialism as practised in Germany. The medical service there was early put under the dictatorship of a 'medical Führer', the Bill will establish the Minister for Health in that capacity."

Most of the staff GPs currently employ are non-unionised and are paid little more than the minimum wage. Even health care professionals such as practice nurses are paid according to how much the practice decides to pay them and not according to NHS pay scales.

There are even differing pay scales between Doctors, with the practice partners employing locum or junior Doctors at a significantly lower pay level than they are paying themselves. In other words, the less the partners in the practice pay in outgoings the more profit there is for them to share.

Therefore, despite GPs attention to detail for certain patients (e.g. those with diabetes, cancer, heart disease) for which they are paid bonuses, most income is predicated on the number of patients on their list and not on how many patients they treat. In fact this situation can be further compounded by partners employing salaried junior doctors to do most of the donkey work, whilst they (as owners of the practice) reduce their own hours.

This has led to a culture whereby managers are employed in many practices to devise ways of providing the minimum of care to their patients. Reception staff are given strict criteria when a patient can see a doctor and those emergency appointments are kept to a minimum number a day. Urgent cases are encouraged to go to NHS Walk-in or Hospital Accident and Emergency departments.

At one surgery in Surrey, the practice partners only work a four-day week (with no evening or weekend working) and each is paid in excess of £100,000 per annum. It is to these people that the Tories propose to hand over almost all decision-making in health care in the UK.

Patients often cannot get to see their Doctors for routine appointments when it suits the patient even if the appointment requested may be weeks in advance. Appointments are often structured so you can’t book well in advance or get emergency appointments at short notice either.

The mantra given at the behest of GP practice managers to harassed frontline staff who often have to face an increasingly angry public is “that people have the right to take time off to see their doctor”, thereby closing down any discussion that Doctors ought to have some form of  service mentality.

It is legally dubious that people have the right to take time of work to see a doctor and not all employers are as helpful as others and it often leads to workers having to take a holiday to see their GP (if they can get an appointment in the first place).

As the BBC has reported "The plans mean GPs working in groups will be in charge of a vast collection of hospital, mental health and community services" In other words it is they who will make the decisions as to our healthcare. For example, it is they who will decide which hospital we will be sent to for treatment.

Unsurprisingly, the BMA said "they could benefit patients and it was looking forward to working with ministers." This should come as no surprise; however there are real and striking problems with GPs being given such discretionary powers.

A common view amongst some GPs is that “patients need re-educating” in that patients are seen to be too demanding in what they expect. A view often encouraged by the fact that GPs get paid mainly by the size of their patients’ list than by how many patients they actually treat.

Sales Reps from Pharmaceutical companies are already adept at wooing GPs in order for them to prescribe more of the medicines they are trying to push, for example providing generous lunches for doctors’ meetings.  The scope for GPs to be offered substantial incentives to favour one hospital/clinic over others will be huge.

Furthermore as part of this privatisation Trojan Horse "Hospitals are to be moved out of the NHS to create a 'vibrant' industry of social enterprises under the proposals." This is yet more 'big society' guff from the Tories, the reality is that hospitals will become profit centres driven by producing shareholder values which will inevitably lead to an antagonistic relationship between health care professionals and finance departments.

If the Tories were really interested in radical reform of the NHS, then it would be the BMA and by extension the GPs who should have the most to worry about. Instead of the subservient relationship we as patients have with our GPs, the reverse should be imposed.

If GPs were paid by the number of patients they see, rather than the number on their list, the dynamic of the relationship between Doctor and patient would be changed overnight. A simple use of a patient's National Insurance number (given to all in the form of a swipe card) or their NHS number would enable state payments to be made to GPs based on productivity.

In many countries in the EU, the Doctor's income level is predicated on the number of patients they can attract to their surgery. This is true for both private and state funded patients. Furthermore the same is true for consultants. The patient doesn't need to have a referral from a GP if they know what's wrong with them (e.g. specific physical injury or the reoccurrence of an already diagnosed condition).

By extension, the same principle should be extended to hospitals and especially the consultants based within them. In what other service provision, would people be expected to turn up in group of 20-30 at a specific time e.g. 9.00 a.m. in order to see an expert, who then randomly allocates whom they see in what order, rather than allotting precise appointment times for each patient?

Hospitals themselves should not be exempted from such reforms. Again, poorly run hospitals with deteriorating health outcomes should not be allowed to continue unperturbed by their failing performance. It is common knowledge amongst many that different hospitals in their area have different reputations. Why should we be sent to a specific hospital by our GP, when most may prefer to go elsewhere?

This would not necessarily lead to redundancies for health professionals, but it would hang the sword of Damocles above management heads. It would be the bosses who would be cleared out not the staff.

There is one other disturbing aspect of what the Tories are trying to do with the Health Service and that is covert privatisation, in a manner that imitates the worst aspect of the health care system in the USA. This is because the system they are planning to introduce gives an opportunity to exploit maximum private profits.

The only discernable rationale to the Tories' changes is that they will be able to convert GPs commissioning groups into Health Maintenance Organisations (HMOs). These private organizations, that were introduced by the Nixon administration in order to drive down costs by limiting access, have a long history of rationing health care for the middle and working classes. They restrict the choice of patients to a few specialists and a very limited choice of hospitals.

In the States groups of GPs, specialists and hospitals band together in a mutually supportive relationship in a HMO. Profits are levered by limiting services to those provided by the HMO and refusing to pay for any service undertaken outside of the HMO's reach unless first approved by the HMO's management. Of course the profits of the organisation are shared by the bodies that make up the HMO.

However, the most disturbing development in the future will be when a private company buys out a GP consortium (with windfall profits for the doctors) and develops a strict policy of vertical integration by only sending patients to hospitals/clinics owned by the same company (or group of companies).

Of, course as part of an inevitable capitalistic development, highly profitable HMOs (i.e. those that can drive down costs as much as possible) have been seen as prime targets for outside investors and many HMOs are now run exclusively for private profit with health care professionals having a submissive relationship to finance departments.

However, the most disturbing development in the future will be when a private company buys out a GP consortium (with windfall profits for the doctors) and develops a strict policy of vertical integration by only sending patients to hospitals/clinics owned by the same company (or group of companies). Ironic if they call it a Health Management Organization. This will be the final nail in the coffin of universal health care in the UK and Lansley's plan will allow it to happen.

It should be the responsibility of the State to fully fund health provision in the UK as set out in the founding principles of the NHS. However, it should not be for the Health Service professionals to decide who is responsible for our treatment. Self-serving interest groups within the medical profession have a long history of preserving their privileged positions. Only by giving citizens the power to make their own decisions will true radical reform of health care in the UK be on offer.