Lansley’s failed NHS reforms: a pyrrhic victory for Labour?

by Rob Marchant

So, government reform plans stymied. The smile wiped off Cameron’s face. Lansley humiliated. Been rather a good few weeks, hasn’t it?

Not so fast. A few thoughts, before we raise our glasses in unrestrained Schadenfreude, might give us pause.

What has certainly happened, over and above any disagreements we might have with them on policy, are two major errors: first, that the Tories foolishly bit off more than they could chew. They tried to completely restructure the largest employer in Europe with a rather hastily-put-together plan, while simultaneously trying to make real terms cuts. They needed an administrator of global stature – think the chief executive of a multinational, the former prime minister of a minor European state, or something similar – to plot out a gradual-but-radical approach to reforming this huge, complex beast over a number of years. Instead they had the luckless Andrew Lansley, a career politician who enjoyed one brief period as a civil servant. In short, this job is not like restructuring the passports service (and look how difficult that turned out to be).

Their second error was political: they failed to win the political support for their ambitious plans, with the public, their coalition partners and doctors. Most healthcare observers are aware that the latter, vital, vested interest has a history of not-very-helpful conservatism with a small “c”: Nye Bevan as health secretary under Attlee famously “stuffed their mouths with gold”, that is, bought them off with a sweetheart deal. Not to mention the public, who have a special fondness for the NHS which often borders on the sentimental, especially when the word “private” is mentioned in the same breath. None of these important constituencies bought into the plan, and the plan failed.

So where does that leave the NHS? With a revised plan, so lacking in any kind of meaningful change as to be worse than useless. Increased productivity through mixing public and private provision (not private funding: a vital distinction) – which Labour first introduced in a modest way, which is practised widely on the continent and which an LSE study has shown to save lives – has been all but removed. Also, bureaucracies have been removed in secondary care, but then others put in their place, which look worse. As the Economist succinctly puts it:

“…a fudge now may well lead to more dissatisfaction and shortfalls in the future. Meanwhile, the rejig has spawned new layers of bodies to ensure accountability. There will be ‘clinical networks’, ‘clinical senates’ and a central, powerful commissioning body with local arms. So much for the bureaucratic cull Mr Lansley once promised”.

All in all, we are no nearer to giving patients the choice and standards of service required for a twenty first century service. As my esteemed Uncut colleague Peter Watt – a former nurse – has pointed out, there are in any case still serious existing problems with standards of care in parts of our health service, a point with which the Economist concurs:

“Scandals over the care of vulnerable patients and hospitals that fall below acceptable standards suggest the service is more prone to failure than its uncritical admirers admit”.

Whether or not you agree with all, any or no parts of the Tory reforms – and clearly there is a big debate to be had – one thing is certain: the NHS for the next few years will function at best the same, and probably worse, than it has been doing to date.

But the real issue is that the NHS is crying out for reform, and any major reform is now surely off the agenda for either party until after 2015. Cameron surely will not attempt it without the mandate of a full majority, and neither will we. Meanwhile, the system will tread water, whilst all the time new and more demands will be made of it, as medical technology advances and, with it, public expectations.

So, we have rightly criticised the flawed reform program of the Tories, and perhaps helped bring it down, although we should perhaps modestly admit that the above-mentioned constituencies were probably much more important than us. And we have bought some time to develop the distinct policy of our own which is so far lacking, still pending the policy review. We have a political win: fair enough. We have done the best we could, from the constraints of opposition.

But, without trying to apportion blame in this complex picture, the judgement of whether no reform at all is better than a Tory reform is a finely-balanced one. There are real losers in this botched outcome of the reform plans: your family, and mine. Who will now wait at least four years for any meaningful reform to be started and, realistically, perhaps ten or more for it to be completed. Ten years more treading water, while we continue to lag behind other countries’ healthcare.

We all deserve better.

Rob Marchant is an activist and former Labour Party manager who blogs at The Centre Left

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15 Responses to “Lansley’s failed NHS reforms: a pyrrhic victory for Labour?”

  1. Tokyo Nambu says:

    It’s interesting to consider if people have the right to choose an NHS which is objectively worse, but they like more.

    I was only half listening, but I doubt it was anything new to people who read the local Barnet press: Today this morning had a piece on the proposed, but postponed, closure of A&E at Chase Farm Hospital. The basic argument was that local A&E makes people feel comfortable, because they want their injured child treated sooner rather than later. The objective fact that major trauma centres have better outcomes for serious cases, while proximity is irrelevant for less major cases, doesn’t seem to matter: people would rather (although they don’t see it like this) die locally then live more distantly. We saw this politically in Kidderminster, and it’s not uncommon elsewhere. Small local hospitals and units evoke huge support from their constituency, and patients rally around; obviously, the dead patients can’t, which is the problem, as Bristol showed.

    The same’s true, mutatis mutandis, for NHS organisation. As it stands, it delivers adequate care (but in many cases not even that) for acceptable (but sometimes a lot more than that) cost. There’s huge sentimental attachment to its structure and staff, so that a government that attempts to be rational will lose in the eyes of the public. But the same budget, sensible managed, could deliver better care (fewer poor quality general hospitals that local people idolise, but knowledgeable service users avoid, fewer sole practitioner GPs beloved of their patients, practicing like it’s still 1973, fewer sleepy semi-rural PCTs delivering local care for local people, etc, etc).

    But it needs the will to change, and people don’t want to. So should a government accept that democracy isn’t technocracy, and offer the electorate a second-rate NHS that they like rather than a first-rate one they don’t? It’s politically explosive either way.

  2. @Tokyo: a very interesting thought. Ultimately they clearly *do* have the right to choose a less good service which they like: that’s democracy.

    But it’s a decision taken with incomplete information, like many decisions are. If the case could be effectively enough made to the public, then democracy *would* produce the optimal outcome.

    On balance I’d say it *is* possible to win this argument, because the public-private mix is more advanced in Continental countries than here, producing good outcomes and showing no signs of wanting to go back: therein lying the proof that a monolithic model does not have to perpetuate forever.

  3. Tokyo Nambu says:

    ” the public-private mix is more advanced in Continental countries than here”

    Yes, but viewed with a sort of “Fog in the Channel: Continent Cut Off” set of blinders on. France’s health system is about fifty percent private, fifty percent state operated: more state in acute services, more private around the edges. It’s underpinned by a massive system of compulsory insurance, so it’s affordable at the point of use, and has very good outcomes. People in England often say “if only we could have French (or German) healthcare, it’s so good”. And yet, the consequence — a substantial reduction in state involvement in provision — would be massively politically corrosive. The French system has as much in common with post-Obama US health provision as it does the NHS.

    Once the state becomes the main healthcare provider, that becomes an end in itself; most of the objections to overturning that are producer dominated, but the consumers listen to the producers rather than the government or policy planners. And so it goes.

  4. This is the most depressing read I have had for weeks. You may as well have started this article saying that you hate the NHS and much prefer private hospitals.

    The Zack Cooper LSE report (note the word, it is not an academic paper) is not peer reviewed so it has as much authority as, well, a newspaper article. I can find non-peer-reviewed papers that proves the opposite as the Cooper report, I can also find peer review papers too. For example there is evidence from the Netherlands (published recently in the New England Journal of Medicine) that shows that competition in healthcare raises costs and reduces choice (the free market does that – the stronger providers buy the weaker ones) and increases bureaucracy and administration (including marketing).

    I have no idea what you mean by “bureaucracies have been removed in secondary care” because secondary care is all Foundation Trusts (2/3 at the moment, but will be all FT under lansley’s plans) and hence there is NOTHING that the government can do about their “bureaucracies” (they are autonomous, remember, which means that the government CANNOT tell them how to provide their services). Lansley’s Bill will do nothing about “bureaucracy” in hospitals, and it is rather clueless for youy to suggest that it will.

    The Economist is also showing its cluelessness: “clinical networks” already exist and clinicians complained because Lansley’s plans for competition would prevent the good work they are doing because existing clinical networks are by nature collaborative. The “clinical senates” are an extension of the clinical networks.

    “we are no nearer to giving patients the choice and standards of service required for a twenty first century service”

    Where have you been for the last decade? Since 2006 ALL NHS patients in England have had the choice of any hospital, and it was only when Burnham became SoS that the NHS became (quite righly in my opinion) the “preferred provider”. If patients choose to use their local NHS hospital that does not mean that they didnt have a choice. As to “standards of service”, well I challenge you to go to the RCN conference and tell them that they do not give the “service” you seem to want. On many international standards the NHS is doing very well, and especially so since it is paid so little.

    “Scandals over the care of vulnerable patients and hospitals that fall below acceptable standards…”

    This is mostly the failings of the social care system – which has been largely privatised over the last 20 years. If you complain about the care of vulnerable patients then perhaps you can do something about it by taking the social care system back under public ownership. And while you are at it, prevent the same thing happening in healthcare by halting the privatisation of the NHS. (Before you mention it: Mid Staffs provided poor care because they focussed on financial controls to get FT status [a hospital must make a annual surplus of 2 or 3% to prove it is suitable to be an FT]. If they hadn’t done that they wouldn’t have cut the staff and care would not have declined.)

    Where we desparately need reform is in social care. There are too many elderly people in hospital who should be in care homes and they are not there because local authorities are desparate to save money and won’t pay for them. Labour’s response to allow hospitals to “fine” social services, is no solution. In my area the local hospital refuses to impose such “fines” because they would prefer to collaborate and help the local authority to provide appropriate social care. Unfortunately, it is regarded as being “anti-competative” for providers to work together.

    There are several inalienable facts. First, there is money, and we do not have to make the McKinsey £20bn cuts. We spend 9%, Germany spends 11% of GDP. Is Germany collapsing because it spends more on healthcare than we do? No. So we *can* spend more, and if we do it will not collapse the economy. Why don’t we have Germany as the benchmark: we could make sure that we spend no more than the German’s do (as %age of GDP). In cash terms, Germany spends 20% more than us.

    Outcomes are improving in the UK better than in many other countries. You seem to want to parrot Cameron’s dodgy figures for some unfathomable reason. Labour’s investment have brought about those improved outcomes so it is bizarre that a Labour site like this does not want to publicise one of Labour’s great achievements.

    Next, the idea that “because the Europeans do it so should we” is somewhat ill advised. The Europeans have the Euro and look what good it has done Greece! Yes our NHS is unique and there is a good reason for it: it is because it works.

    Seriously, there is little evidence that private sector can save any money at all. In fact it will probably cost more. For example, Circle Health run one of the ISTCs (at Nottingham) it is paid 20% more than the NHS, it is allowed to cherry pick patients (ie, it sends complicated cases back to the NHS *and* gets paid for the patient it did not treat) AND Circle makes a loss. Given that it has all of those advantages over the local NHS provider it should make a whacking great profit. It doesn’t. It is about time Labour shouted from the rooftops how cost-effective the NHS is.

    Finally, som verifiable figures: an NHS hospital is paid £741 for a cataract removal, ISTCs are paid £939 and private providers charge £1800+ so please explain to me why you think the private sector can save any money at all.

  5. william says:

    Richard Blogger.The cuts are there because of the huge ongoing level of state borrowing(cf. Germany).Labour’s ‘investment was in GP salaries and staff numbers, with negligible increase in productivity and outcomes.A great achievement?A vast bureaucracy providing one of the worst health systems in Europe.The NHS is equally as successful as its rival in employment terms,the railways in India.Free at the point of delivery is OK,but a GOSPLAN monopolist for healthcare is designed to favour its almighty employees, rather than its clientele who finance it .1947 was some time ago.

  6. @Richard: despite making some good points, your comment is somewhat exemplary of what I’m talking about in the article: that otherwise intelligent people find it impossible to discuss the NHS without getting quite emotional about it. It is quite unnecessary to describe other people’s views as “clueless”, and you could learn a little debating courtesy. I shall endeavour to answer your points nonetheless.

    Before doing so, I should like also to point out that, from the unjustified conclusion in your first sentence onwards, you have read into my piece an opinion that isn’t there. You want to paint it as a roll-over-and-accept-the-Tories-are-right piece. It is not, if you actually *read* it. My more nuanced point is that it is a complex debate where the Tories have taken some of our ideas and then done things in a different – and botched – way: not everything they have done is wrong, and clearly not everything is right, either.

    Regarding the Zack Cooper report, it is not peer-reviewed academic research, however it is evidence-backed research from a reputable source, and however much you would like to paint it as low-quality journalism, it is not. I would also add, that for all you may disagree with its conclusions, the Economist is one of the highest-quality examples of journalism you are

  7. likely to find.

    On clinical networks and clinical senates, I’m not sure on what evidence you think all this is improving efficiency. Your comment about standards of service and the RCN conference is risible: going to a group of any such professional organisation and suggesting they could do their job better is unlikely to meet with smiling faces: this does not mean that they could not, though. It is a matter of approach, and you could apply that to any trade union (or, frankly, any other vested interest). The patient’s outcome is, in the end, what counts.

    On social care, I agree with a lot of what you say. However, it is to be in denial to suggest that hospitals could do with no improvement: the verbal equivalent of sticking your fingers in your ears.

    Your use of the word “privatisation” is typical of a mindset which refuses to countenance anything except a monolithic system, and does not distinguish between privately-funded (which I and most other people don’t want) and privately-run (which clearly can and does work).

    Your single, anecdotal counterexample does not, I’m afraid, give the lie to private sector efficiency savings. The NHS can be very cost-effective in some areas. In others it is not.

    Your cost comparison of NHS/ISTC probably does not take into account equally hidden costs in NHS and ISTC, although I would like to see the source. The “fully private” costs are irrelevant, anyway: we are not looking to replicate them and they are based, for a start, on a “premium service” and a private insurance system with incomplete coverage (the whole point of *having* an NHS is to avoid this). If they want to make lots of money from their patients, fine, but it’s not at all relevant to the important comparison, NHS vs ISTC.

    The European comparisons I made, by the way, were not, as you have wifully misinterpreted them, to say we should try and replicate the French or German services. What I *was* saying was that in the mixing of public and private, the French at least are more advanced, and it seems to be working. There are other aspects of the French system which are less good and where we are better.

    Richard, it is precisely thinking like this, that any suggestion of change is bad, which is causing gridlock in the debate and harming, ultimately, the very patient outcomes which you profess to want to sustain and/or improve. Finally, as William says above, you say that “we *can* spend more, and if we do it will not collapse the economy” as if public finances were a bottomless pit. They are not.

    We *can* spend more on health, but we will need to spend less on other things. You can start by telling me what other public services you would cut to reach French or German levels of spending.

  8. @William: I agree with you that public finances are not to be ignored. I do not agree with you that all Labour investment in health was wasted: it wasn’t. The NHS was in a parlous state by 1997, and badly needed the reinvestment it got. What should, however, have happened was sustained and radical reform in tandem with that investment, which seemed to get lost by the end of the decade. The Zack Cooper report is a good testimonial to the parts where Labour got things right.

  9. RichardT says:

    “Why don’t we have Germany as the benchmark..”

    Whoever you choose as a benchmark there will be lots more private spending on healthcare. Even the Germans spend twice as much as us (as % of GDP) privately, France 4x. Our public spend is around or above OECD average, our private spend well below.

  10. @Rob

    Let me set my stall. I am a Foundation Trust governor and this is something I take seriously. So it means that I regularly go out and talk to the community (not just members, usually I try to engage with non-members). What I find is that there is a percentage of people who would not touch the NHS with a bargepole. Fine, I am happy with that; there are people who do not want to live on council housing estates either and they express their choice by buying expensive houses in gated communities. The majority of people I talk to want to use NHS providers, and specifically their local hospital. Their concern is that the quality is high and that access is prompt, they do not express a choice to use another hospital.

    I fail to understand why the choice agenda seems so important to politicians when it is clear that to the public choice is a minor issue. The Bill (neither original, not amended) will address quality, access to treatment or accountability; the things that people are concerned about. This is why I am fully against the Bill. As I said above, a lot could be achieved by integrating health an social care and – crucially – pay for both from the same budget. I recognise that this would be a radical change because local authorities jealously guard their social care responsibilities, but it will make a huge difference for patients and cut a lot of waste.

    Incidentally, I did read your article and I disliked the tone (have you read any of mine over at False Economy? Perhaps you could learn some things from them.). For a start the NHS is not a static organism: it changes constantly and does not need a re-organisation to change. The attitude that “we have to change it now or it will collapse” is nonsense (or as you put it “the NHS is crying out for reform”, I say: no it isn’t; leave it alone, sort out social care instead). As to there being a “political win” well I’m afraid I have to disagree. The amendments have changed very little, Monitor will still force competition on us (instead of “promoting competition” they will act against “anti-competitive behaviour”, what’s the difference?).

    I know that the Monitor decision will be a disaster for my community because my hospital is rural and has an effective “monopoly”. However, we are one of the most efficient hospitals in the country (on reference costs) and have high levels of care. But since we have just taken over Community Health Services and are developing an integrated system where acute and community care work closely together, it could easily be described as becoming more “monopolistic”. I suspect that in the next few years Monitor will step in and break us up (as “anti-competitive”, but who will benefit? not our patients, that’s for sure). Remember, few people want “choice” and yet such an action from Monitor could break up something valuable.

    I’m sorry that you took offence at my robust arguments, but it is a pity that you did not address the issues I raised. “bureaucracies have been removed in secondary care” what did you mean by this? As an FT governor I make it my business to talk to the executive board of my hospital and the main bureaucracy I find is the internal market. Do you know why hospitals charge for parking? It’s the fact that hospitals are treated as businesses an MUST have an income from every asset, which includes their car park. Get rid of the internal market and the ludicrous idea that hospitals are businesses and we can do something about car parking. Labour promised to get rid of the internal market in 1997 (remember that date? we won a landslide then) and then reintroduced it (no more landslides after that, could there possibly be a connection?).

    As to debating curtsey, well, when I come across an evidence free article it riles me. I campaigned very hard before the election against the Tories because I knew what they were planning for the NHS and it disgusted me that Labour did not campaign on their great achievements. I view your article in a similar vein. I will be at Conference in September perhaps you would like to debate the NHS with me then – if I promise to be courteous?

  11. @Richard:

    “The Bill (neither original, not amended) will address quality, access to treatment or accountability” – I agree. That is the whole point of my article, that the current Bill leaves us where we were, or worse.

    Regarding choice, as you said earlier, the choice of hospitals is already pretty much enshrined in the system. But you are taking a very narrow definition of choice. When policymakers talk about choice, they mean it in a broad sense, which cuts across all public services.

    They want the same ability to choose a public service that private companies provide when they provide a service. It is not just about choosing a hospital: it’s about choosing the manner of delivery of a service. The when, the where, the how. People want services in the 21st century delivered with the same flexibility and quality as they get from every non-state provider. You may be right that people don’t care about choosing a hospital; they damn well do care about how their healthcare is delivered to them. At the moment the quality is variable and the flexibility is low. The provider decides everything and has low incentive to improve, because very little happens differently if you underdeliver or overdeliver.

    I am not against integrating health and social care. And I don’t understand why you are so exercised about car-parking, either. You expect to pay to park your car for shopping in a town centre, why on earth not at a hospital? Does it affect the quality of care? No. As an example of your resistance to change, this has all the hallmarks of being dogmatic rather than rational and case-by-case.

    The problem with this digging-in of heels, exemplified by your missing completely the nuances in my article, is that it is actually grist to the mill of the more right-wing Tories who really would privatise the lot, given the chance. And this is what may well happen if and when Cameron gets a full majority. I don’t read False Economy, by the way, because I find it tiresomely, dogmatically anti-cuts in general (which is not even Labour policy, by the way). Some cuts are inevitable, full stop, and would have been under any government. The easy thing is to pretend otherwise; the hard thing is to decide where they would fall.

    I would be delighted to debate with you further, if we can limit ourselves to the issues.

  12. I didn’t see your second part (the moderation of this site keeps comments in limbo for a long time), so I may as well respond to that too.

    “it is to be in denial to suggest that hospitals could do with no improvement: the verbal equivalent of sticking your fingers in your ears.”

    As I mentioned earlier, there is no fingers-in-the-ear with me, I know on the ground what is happening in my area in NHS. I am aware about the issues in social care, I am also aware of the level of care provided by our hospital. I have not said that they cannot improve, but it would bore you if I gave details of the areas where improvements can be made (and you will dismiss it as “anecdotal”). As I mentioned before, which you seem to only be mildly aware, is that too many people are being failed by social care, and the NHS, as the last safety net of the welfare state, ends up fixing the problem. I am quite critical of Burnham in many respects, but in one area he was spot on: social care is what needs fixing. Your tone is that hospitals are the problem without mentioning what the problem is. I am politely filling in the gaps in your knowledge.

    “Your use of the word “privatisation” is typical of a mindset”

    Oh dear, rather than addressing the issues I raise, you decide to attack my “mindset”. As it happens I am not against private sector involvement, but on our terms, not theirs. After all, if a ward is refurbished the people doing the work are most likely contractors not NHS employees. The food you eat will be grown on the farms of some large corporation (over which we have no accountability) and the drugs will most likely be imported from abroad. (Heck, I take two types of insulin. One is made in a mega factory in Brazil and the other in a factory in Puerto Rica. Neither of which is a workers’ collective. Both of which make profits for foreign shareholders.) However, when it comes to healthcare provision (as I explain below) the private sector does not have the responsibilities for a community.

    It is not acceptable (as some argue) to say that electives can be private and A&E is public sector because without the elective work there will not be the expertise to provide the treatments for A&E. The reason why the NHS works is because for 60 years we have realised this benefit. In my opinion, the private sector should be used to add extra capacity when it is needed – short term use to get local waiting lists down, for example. And what’s more, we should expect to pay more for that, just like companies pay more for temps. But handing entire elective services (as in the case of ISTCs) to the private sector is bonkers.

    Here’s one simple reason why private provision is not in the service users’ interest (see what I did, I avoided the p-word so that I won’t get the Blairite knee-jerk from you). A private hospital can be here today, gone tomorrow, and there is nothing that patients can do about it. If a service is not profit making, then they will drop it as soon as they can. If the private company goes bankrupt then they can drop it immediately. NHS hospitals cannot do this: they *have* to provide the service, regardless of whether the patient requesting treatment has multiple complications and needing expensive care. We have seen how this distorts the market. ISTCs were paid 11% more than the NHS (and in the case of Circle Health, 20%). They do not have the responsibility the NHS has.

    Why does this matter? Well NHS hospitals provide services for the *entire* community and some services are provided even though they make a loss. I know you dislike anecdotes but at least they are content, rather than the content-free bluster. My local NHS hospital makes a surplus on every service except paediatrics and A&E. The reason is that the area has a far more elderly age profile than most areas, so there are more people being admitted with hip fractures than in most areas, and there are too few children to make employing the paediatrician and specialist nurses economic. However, the hospital provides both as a social benefit for the community, and subsidises this with the surplus from other services. If the hospital was private it would not have A&E nor paediatrics and the community would have to use the next hospital 15 miles away.

    We are seeing such an issue at Hinchingbrooke at the moment. Although Circle has been appointed, the contract is still being negotiated. Its a pretty sure bet that once the contract is signed Hinchingbrooke under Circle will provide fewer services than it did when it was under NHS management.

    If you want to see data about ISTCs then I suggest you have a look at the work of Allyson Pollack, unfortunately I cannot find a web link, but this article is a good place to start BMJ 2009;338:b1421.

    “Your cost comparison of NHS/ISTC probably does not take into account equally hidden costs in NHS and ISTC”

    There is no risk taken on by the ISTC. They were paid by “take or pay” which actually means they are paid even if they refer the patient back to the NHS without treating them. ISTCs also have a guarantee from the Department of Health that the DH will buy their facilities at market rates if the ISTC ciontract is not renewed. All of this is open and widely known. The figures I gave for ISTC is from a study I did a year ago. The figures are here (including sources). The £939 figure is from Hansard for the Ophthalmic Chain Cataract Initiative provided by Netcare Healthcare. This contract is worth £42 million and for this money the clinic performed 44735 operations or £939 per procedure. The figure for the NHS is from the National Tariff (Dept of Health website). For private costs, here is an ad from my local newspaper

    Do you believe me now? I would love to be paid to check the private sector price lists against the costs of NHS treatments but no one seems willing to do that 😉 Anyway, the private sector is generally not willing to provide information about their costs, nor their productivity figures. However, it does not matter because the majority of NHS spend in hospitals are in a handful of procedures like hip replacement, cataract removal and hernia repairs. And in all of these cases the private sector is always more expensive than the NHS. Sorry, but you cannot use cost as an excuse for introducing private sector provision.

    Re: the French or German systems. If the NHS had the funding levels of those systems we would have far better outcomes. Seriously. At moment the French system is having serious financial issues with hospitals going bankrupt in some areas, and recently one of the large German health insurance company was close to collapse. International comparisons are rarely illuminating or instructive.

    “We *can* spend more on health, but we will need to spend less on other things. You can start by telling me what other public services you would cut to reach French or German levels of spending.”

    Huh? I gave relative values in terms of GDP. If the French and Germans can spend more, in terms of GDP, why can’t we? Are you seriously suggesting that Germans go without the luxuries that we have because they spend more than we do? And that we have to go without something vital to get their level of healthcare spending? No. Liam Byrne’s adage is not correct: we can always find more money when we need to (to bail out the Irish, or start yet another war, for example).

    “The provider decides everything and has low incentive to improve, because very little happens differently if you underdeliver or overdeliver.”

    Again, this is coming from a position of ignorance. The provider does not decide everything. We have standards in clinical care and standards exist to make sure that we do not have a postcode lottery. This is a good thing and I hope you agree that we should have them to ensure that we do not have variable quality treatment across the country. The term “incentive” is nasty. Of course there is an incentive. It is called the Hippocratic Oath. I think you have yet again insulted hundreds of thousands of NHS workers by suggesting that they deliberately deliver poor care “because they cannot be bothered to do it any better” or there is no incentive to improve.

    The reason why I mentioned car parking is because I wanted to indicate the effect of the internal market: a hospital *must* charge for parking because otherwise it will not be getting a return on an asset. (While we are talking about assets, did you know that all English hospitals are worth £24bn. Interesting that the Department of Health saw fit to add that figure up, don’t you think?) I did actually spell out why I mentioned car parking, it was a pity that you latched on the trivial part rather than the more important point that the internal market is the issue.

    I am always willing to debate, let me know when and where.

  13. cityeyrie says:

    RM:RBlogger’s points ‘sentimental’? Everything was backed by evidence. Calling someone ‘sentimental’ who provides evidence for their arguments reveals a frightening denial of reality.

    What the LP don’t seem to get (or don’t want to get) is that privatisation has already wasted huge amounts of NHS money, whether in the form of PFI deals or ITSCs – or in all the management consultants, lawyers and accountants fees its taken to negotiate the the twists and turns of the market takeover of the NHS, particularly over the last ten years.

    When these current costs of privatisation are stripped out of the NHS, get back to me about where other savings should be made, and how.

    No doubt some things needed to change. During a bout of healthcare activism before the election, I was shocked to find how opaque and obstructive the local PCT was, My first FOI request was refused on grounds of ‘commercial confidentiality’, just by way of example. Also that they were turning into a commissioning-only body anyway, that the system of turning hospitals into foundation trusts had set them up in competition with community primary care, that by 2013 (not 2011 as actually happened) no one would be directly employed by the NHS any longer. This was all put in place by Labour, without much debate (was there even a bill to institute ‘World Class Commissioning?). In a way I welcomed how Lansley’s bill woke more people up to what’s been going on for some time now.

    The LP’s continued support of (limited? is this possible?) market encroachment and lack of ideas about any alternative means their comments against Lansley’s bill have rarely hit home. Yes the reform of the reforms isn’t Labour’s victory, but that of the many professional and campaigning bodies who oppose it.

    Until the LP itself stops touting its own brand of market fundamentalism, little it says about the cuts, the health bill etc will have much credibility.

  14. lost_nurse says:

    Excellent posts, RichardBlogger. Well said.

  15. As I said above, we *can* afford to increase spending on the NHS. And that is not me saying that, it is Prof John Appleby of the Kings Fund (summarised here on the Telegraph website, the BMJ is subscription)

    Appleby concludes: “Spending on health will be a matter of choice, not affordability.”

    What better choice is that for a government to make: to pay for high class healthcare for its citizens! If we continue to go ahead with the McKinsey £20bn of cuts it is because the government has chosen to do it, clearly showing that they think the public are not worth it. I do hope Labour does not make this mistake too.

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