This extraordinary post was first published on the False Economy site – which is always worth reading. It’s incredibly important at a time when the government claims that NHS reforms are not about privatisation when their actions so very clearly show that they are. As such I reproduce it in full, I hope with their agreement:

Campaigning for the 2010 election, David Cameron said “in place of Labour’s self-defeating top-down targets, we will harness the power of information and publish the details of healthcare outcomes.”

He said that he would get rid of the Labour government’s “process drive, top-down targets”.

After not winning the election, but still becoming Prime Minister, Cameron was true to his word and abolished the NHS targets.

However, as Lansley’s ill thought out reorganisation started to divert resources from frontline care, waiting times started to rise.

Worried about the public backlash, Cameron reimposed the waiting time targets. Cameron made dropping targets a big issue of his election campaign and yet within a year he had re-imposed them.

Now we see that he is about to impose another target. Cameron’s new target is how quickly he can privatise NHS care.

The Operating Framework 2012-13 is the rule book for the NHS. The technical guide gives a list of “indicators” that the Department of Health uses to determine if PCTs are implementing the requirements of Operating Framework.

One of these indicators goes by the snappy name of:

PHF09: Trend in Value/Volume of Patients Being Treated at non-NHS Hospitals

This says that PCTs should collate the number of patients the NHS have paid to have treatment in private hospitals.

Since there are private providers who are paid to do NHS work, there is no problem with monitoring how many patients use them. However, the reason for this indicator is not merely to “monitor” this patient choice. The explanation is:

“Patients should have the opportunity to choose a range of providers for their first outpatient appointment, including those in the Independent sector. This indicator shows a percentage of patients who have exercised choice, since it is likely that an alternative NHS provider was also offered to them. An increasing percentage of CAB bookings being made to the IS may be indicative of more choice being offered to patients.”

CAB is “choose and book” which is the system where patients choose from a list of providers – NHS and private (IS, or independent sector).

The last sentence is shocking. The government says that patients must have choice and the only way that they can be reassured that patients have had a choice is if the percentage of patients who have chosen a private provider increases.

A PCT has to show that patients were given choice, so a PCT must make sure that more patients choose a private provider. This indicator does not take into account that when a patient is given a choice, they may choose to use an NHS hospital: the government does not treat this as the patient choosing. Their only measure of a patient choosing is if patients choose someone other than the NHS.

All political parties say that NHS patients should have choice, but the current coalition government take a Henry Ford attitude to this choice. Rather than “any colour you like as long as it is black” the government is saying “any choice you like as long as it is not the NHS”, and they have set a target to increase the number of patients choosing a private hospital.

Richard Blogger writes about the NHS and social policy at NHS Vault.

As the Guardian reports this morning:

Medical leaders are urging the government to end its “astonishing” refusal to publish its own assessment of the risks its NHS shake-up poses for the service and patients.

The leaders of Britain’s doctors, GPs, nurses and midwives are among an alliance of senior figures in healthcare who are demanding the release of the Department of Health’s (DH) analysis of the dangers involved in the radical restructuring of the NHS in England.

It should be made available “forthwith” so that parliamentarians scrutinising the health and social care bill can be fully informed about it before they give it final approval, they say.

Full marks to Labour for bringing this issue to the for.

None to the Lib Dems for ignoring it.

The reality is that more than 2,000 past risk assessments in thew HNS have been published oin a timely basis to informa decision making. But not this one, which the governemtn is refusing to disclose.

There can only be one reason for that refusal, which is, of course, that it is damning.

I am sure it is damning. Whatever the motive for this legislation it cannot work and competition will harm, and probably wreck the NHS. The bill for compensation to companies – any company – that wants to sue for not getting a contract, as they will be able to do under EU law,  will run to billions alone.

And then there’s the simply fact that this change cannot be imposed on an NHS that is also being forced to deliver cuts.

This risk assessment almost certainly says this Bill is a disaster in the making.

And that’s hy it is not being published. Today Labour try to change that. But as ever the Tories are simply ignoring democracy and duty to steam roller their destruction of the NHS onto the statute book.

The Guardian summarises those invited and not invited to the NHS summit at Downing Street as follows:

INVITED

Royal College of Physicians (London)
Royal College of Surgeons of England
Royal College of Obstetricians and Gynaecologists
Royal College of Paediatrics and Child Health
Royal College of Anaesthetists
NHS Confederation
Foundation Trust Network

NOT INVITED

British Medical Association
Royal College of General Practitioners
Royal College of Nursing
Royal College of Midwives
Royal College of Pathologists
Royal College of Radiologists
Royal College of Psychiatrists
Royal College of Opthamologists
Chartered Society of Physiotherapy
Faculty of Public Health
British Association of Occupational Therapists and College of
Occupational Therapists
College of Emergency Medicine

There is an almost perfect split between this invited and not invited.

Those invited can profit from the extra private practice that can reasonably be presumed to result from the Tory changes, so are expected to support them due to their personal conflicts of interest.

Those not invited will not profit from those changes as many (but not all, I agree) enjoy little or no private practice. So they can be objective and as such see through the madness inherent in the proposals.

The split is just about as simple as that.

I’ve been tweeting a fair amount on the NHS this weekend. I’ve hardly been alone!  The issue of NHS reform is now firmly back on the table – but certainly not in the way the government wants.

No one denies the NHS needs reform. Not because, I hasten to add, of the reasons the government gives. The NHS crisis is not an ageing population or healthcare inflation: those are things we have to afford come what may. The NHS crisis is that for over twenty years now politicians of all hues – and I make no exception for Labour here, some of whose Secretaries of State were disasters (starting with Milburn but with Reid running a close second) – have believed markets were the answer for the NHS. They’ve all been wrong. Markets cannot ever be the answer for the NHS, as I explain in the Courageous State, where I say:

There are, without doubt, certain conditions that must exist before any market can operate, even imperfectly. The first condition is that there have to be willing buyers for the products. Without such buyers there is no chance of selling products, let alone at a profit. Second, if abuse is to be avoided as a result of monopoly profits being made there has to be competition in the marketplace.  If there were, for example, to be only one commercial supplier of an essential service, such as healthcare, then the opportunity for price abuse would be enormous.  This is especially true when purchases of healthcare frequently arise in situations of high stress when the opportunity for finding an alternative supplier is limited (or to put it another way, the purchaser is almost invariably at a disadvantage to the supplier at the point when they must buy because they are in pain and far from being able to make an objective decision).  Only competition and informed decision-making can, to some extent, limit that opportunity for abuse of the consumer and even then only if what is called oligopolistic behaviour can be avoided.

Oligopolistic behaviour happens when there are just a limited number of suppliers in the market and they can, whether explicitly or otherwise, cooperate to ensure that they can collectively earn monopoly profits that are exploitative. Precisely because informed decision-making on issues such as healthcare or pensions (for example) is very hard to achieve the private supply of these services will always be open to considerable abuse, as the failings of pension privatisation have already proved.

But even if competition could help when informed decision-making was possible it is also true that competition also has a downside. This downside is that, by definition, competition requires that there is excess capacity in a market. There can be no such thing as effective competition if every single supplier in a market is operating at full capacity: in that case, there is no opportunity for choice (whether informed or otherwise) on the part of the consumer. That consumer is left, if all suppliers are operating at full capacity, having to take whatever opportunity might be available to them at the supplier’s convenience, and at the supplier’s price.  However, this means that to be effective competition is dependent upon all market participants always working at less than full capacity, which means that competitive markets must always (whatever the theoreticians may say) be inherently inefficient in practice because all participants in the market must be underutilising the resources that are available to them if the consumer is to get the choice that they desire.

In other words, because we cannot afford duplication in health care and because we are bound therefore at the very least to have oligopolistic suppliers however health care is organised if we have a market for it and because consumers of health care (who I much prefer to call patients) will rarely make informed decisions so called health care markets are bound, inevitably, to deliver sub-optimal outcomes.

In which case we’re better off kicking any pretence at market supply out of the NHS and instead organising it to ensure best quality health care is supplied.

That requires wide regional coordination covering all of health and social care under one management for a large population. How large? Probably 2 million or so to allow several hospitals with non-competing areas of expertise, widespread dissemination of bets practice and as far as possible elimination of post code lotteries and variances between local authorities – who would none the less need to be well represented in the process alongside medics from across the NHS and not just GPs.

And if the focus is on care and cost is reduced by cutting out the vast amount of wasteful trading for internal costs which has inflated NS admin ridiculously then we have the basis for a viable, coordinated, health care system that works from cradle to grave, from place to place and from need to need.

That’s what Labour has to demand now. But it too has to drip its fixation with markets to deliver this. Because only then can we afford what we want.

It’s not the substance of the following report in the FT on NHS reform that is interesting, it is the form of wording used:

As Andrew Lansley’s NHS bill slips deeper into the mire, amid ever more noisy opposition from doctors’ and nurses’ trade unions, there are still bits of the mess that can be rescued.

The assumption seems to be that in the face of opposition the governemtn hnow has little chance of getting its NHS reofrms through.

That’s a massive change in the narrative if true. And it may not be what the journalist meant. But it reads that way, and I like it.