“Mud sticks”
The Canadian model is built on a recognition of the limits of markets in distributing medically necessary care. Most markets distribute goods on the basis of supply and demand, with price signals used to affect production and consumption decisions. When price drops, demand should increase, with a near-infinite demand for free goods. Conversely, with fixed supply and high demand, price should rise until enough people get priced out of the market to balance supply against this new (lower) level of demand at the new equilibrium price.
Yet health care markets stubbornly refuse to follow these economic laws. Economists have debated why this is so and whether they can force health care to behave in accordance with theory. In Canada, there is remarkable tension with power being devolved to the provinces, meaning that if anything goes wrong, it is hoped that central government can escape the blame.
This latest set of ‘top-down reforms’ of the NHS are estimated to cost £2bn, and the widespread perception is that the system has been thrown into chaos because of a lack of fundamental understanding of the pre-existing culture of the NHS and overcoming the “barriers to change”. GPs in the UK are likely to be the ‘fall guys’ for this failed implementation. When the US sneezes, the UK catches a cold. We can already see this phenomenon being rehearsed ad nauseam across the pond. For example, in a recent American blogpost, “Who is to blame for the current healthcare crisis?” , Dawn J. Lipthrott comments that, “Doctors are to blame when they try to make up loss by over-scheduling and growing careless, or by failing to communicate with their patients.
The devolution of power to the locality is critical in ensuring that as much blame can be directed locally as possible. Of course, the idea of real local democracy is an illusory one, when you consider the emotional trauma local residents of Lewisham or Mid Staffs, for example, have experienced.
The Royal Free Hospital in its guide to NHS Foundation Trusts writes,
“The introduction of NHS Foundation Trusts represents a profound change in the history of the NHS and the way in which hospital services are managed and provided. NHS Foundation Trusts are a new type of NHS Trust in England. They are part of the Government’s plan for creating a patient-led NHS. The aim of these reforms is to provide high quality care, shaped by the needs and wishes of today’s patients, in the most efficient way. NHS Foundation Trusts have been created to devolve decision-making from central Government to local organisations and communities so they are more responsive to the needs and wishes of their local people. They are also at the leading edge of many of the other reforms and improvements that are creating a patient-led NHS.”
Meanwhile, the scandal-hit Mid Staffordshire has just become the first NHS foundation trust to be put into administration, The sector regulator Monitor said it has appointed two trust special administrators to “safeguard the future of health services” currently provided at the trust.
The “Local Government Lawyer” magazine writes in February 2013:
“In conclusion, local authorities have unique powers to scrutinise NHS functions, to call for information and explanations, to question proposed plans, and to invite senior managers to attend and provide evidence. However unwelcome their attentions may be, they do have a responsibility to exercise these powers “positively and proactively”, and that includes recognising that the function goes beyond the occasional attention of well-intentioned but lay members, to include demanding the information and providing the professional resource and competence to be able to do the job effectively.”
The notorious Section 75 regulations – set the legal framework for NHS competition under the government’s health reforms. They have already been revised once, after opposition to an original version from both the Liberal Democrats and Labour.The original plans would have seen NHS trusts forced to ask private companies to bid for every service, even if commissioners were satisfied with the way it was being run by the public sector. The new revised regulations insist that Clinical Commissioning Groups must invite bids for services in all cases except those which they are sure can be provided only by the current provider. This will mean only the most difficult and expensive contracts will be held by public sector organisations, as private companies will say they are capable of providing all others.
The concerns were confirmed by a recent Lords committee, which said the revised rules were “substantially the same as the original regulations”. Although many members of the committee said the new wording was an improvement, they also warned: “The wide range of interpretations of the substitute regulations is, we believe, likely to translate into uncertainty about how they will operate.”
Even with the new section 75 NHS regulations, when the private providers take the CCGs to court over the tenders, and the judge rules against the CCG on the process grounds of openness, transparency, Wednesbury reasonableness or even proportionality, and there is a huge public outcry, the Department of Health can easily blame the CCGs for a failure in the procurement process, especially as they do not have a comparable skill-set for doing slick procurement. It is widely believed that the new regulations lack sufficient clarity, so that the litigation option outside Monitor can easily be exercised by private providers.
The LibDems, of course, don’t want any of the mud sticking to them. The Liberal Democrat Lords health spokeswoman Baroness Jolly said she had received assurances from health minister Earl Howe that critics’ fears about the revised regulations were unfounded, and that this would be made clear when healthcare sector regulator Monitor published its guidance on them. That news only came a day after a coalition of influential charities, including Marie Curie Cancer Care, Sue Ryder, and Help the Hospices issued a parliamentary briefing warning that the new rules could mean competitive tendering for NHS services becomes “mandatory in all but the most exceptional circumstances”. On the other hand, the controversial regulations should be withdrawn, according to the BMA ahead of crucial Lords debate on 24th April 2013.
Meanwhile, the media is already gearing up to blame the CCGs. In March 2013, it was reported that one in three GPs who are running new organisations that are about to be given £65bn of the NHS’s budget also help run or hold shares in a private healthcare firm, a study shows. The disclosure has sparked concern that such widespread conflicts of interest will threaten patients’ trust in GPs, who they may see as lining their own pockets out of public funds. Overall 426 (36%) of the 1,179 family doctors on a board of one of the 211 clinical commissioning groups (CCGs) in England have an interest in for-profit firms, including those providing common NHS services such as diagnostics, minor surgery and out-of-hours GP care, an investigation by the British Medical Journal (BMJ) found. Some of them, it is alleged, are senior directors of such firms, while others have a shareholding in major private health companies such as Harmoni and Circle Health, which already earn hundreds of millions of pounds a year for doing NHS work alongside local doctors.
As usual, the LibDems are ferreting around to make sure that none of the mud of the failed section 75 NHS regulations sticks ultimately with them. You have to be either beyond stupid or fraudulent to claim that the current regulations are workable, even with the veneer of ‘integrated care’, as CCGs will be forced into a competitive process unless there are drastic reasons. The whole situation has gone beyond pathetic now, and is not even worthy of a ‘The Thick of It” script. Mud sticks: the new section 75 NHS regulations once enacted will be the ultimate disaster.
