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Labour and the NHS – we need to talk about principles!

May 12, 2013 10:02 pm / 2 Comments

Please note that the title of this blogpost has changed since first publication.

White Elephant

Think of how much time we’ve just all spent, in thinking about the way in which services will be mostly put out for competitive tendering in the National Health Service. One of the first rules in law is that you fight your battles to the hilt, but, at first, you pick the right battles first. This is precisely what Labour appears not to have done. When Harriet Harman recently said on Question Time that the Conservatives are definitely not ‘to be trusted with the NHS’, Harriet curiously did not refer to the battle and war just won by the Conservatives (and Liberal Democrats) over NHS procurement. And yet the public desperately want Labour to stand up for the NHS. One member even suggested that, if Labour gave its unequivocal backing for restoring the NHS, Labour could even find itself with a massive vote winner.

Labour is clearly going through policy strands with a fine tooth comb, looking at, for example, the way in which multinational companies might employ workers at below the national minimum wage; effectively, controlling immigration through a wage policy. It does not appear to have worked out unequivocally whether it would reduce the rate of VAT, meaning possibly that the state borrowing requirement would temporarily increase. But do you see what they all did there? For days, weeks, or even months, we have been subjected to a relentless debate about EU immigration, when most surveys probably place the issue at number ten on the list of voters’ concerns. Unsurprisingly, the economy remains in ‘pole position’, but the ability of Labour to turn the opinion of the public, particularly in the South of England, away from the idea that Labour is ‘fiscally incontinent’ remains unconvincing. Labour is still considered to be the “tax and spend” party, for example, and Miliband appears painfully aware of that. So, when it comes to policy, there seems to be an odd combination of Labour shooting itself in the foot, or completely picking the wrong battles. And then you add in a complete inability to look at elephants in the room. Labour, to state the obvious, has no ability to implement any of its policies, if it is unable to win a General Election, and the confidence of Labour to win an election on its own is reflected accurately in Lord Adonis promoting his book that ‘if he were to form a new Lib-Lab pact, he wouldn’t start from here.‘

The NHS remains pivotal in Labour’s electoral chances, and Labour has been unable to use the resentment over the section 75 NHS regulations to maximise political capital. Why this should have happened in itself is interesting, as Andy Burnham, MP for Leigh, is a more than capable Shadow Secretary of State for Health. One of the issues is an ability to choose the right battle, possibly. Burnham, with some support from the right-wing media and thinktanks, has been banging on about integrated and whole-person care. Whether through conspiracy or cock-up, there will be short-term interest in how integrated care might be delivered. Think about a justification for State spending in the ‘mission impossible’ of implementing a NHS IT system. Why on earth would a right-wing libertarian government promote something which is national? Why on earth should you abort an ethos of ‘bonfire of the QUANGOs’ to introduce the biggest QUANGO in the country, viz NHS England? Whether you’re into conspiracy or cock-up, the integration of financial and medical information (including mental, physical and social care systems) allows for the perfect infrastructure for an insurance-based system. Insurance works on the basis of misrepresentation or non-disclosure to invalidate claims, so ‘big data’ serve a perfect storm for this. It won’t have escaped anybody’s attention that Labour (as indeed the Conservative Party) has been heading towards an insurance-based system for social care, so it does not require a massive ideological leap to think how this could be extended for all care with time. This does not involve any degree of paranoia, please note. BUT this interpretation of a sinister agenda for integrated care is misfounded, in that everyone agrees that better coordinated care can only be to the benefit of healthcare, and seeing the individual as a whole person is completely consistent with a major tranche of recent health polciy.

There is overwhelmingly an intellectual depravity in the bereft notion of producing policy through poll results and focus groups. New Labour clearly loved focus groups, with Philip Gould in ‘The Unfinished Revolution’ having devoted much airspace to developing a product in line with customers’ wishes. Of course, the Conservatives have a special affinity for polling organisations themselves, Nadhim Zadawi, in 2000 he co-founded YouGov and on its flotation became its CEO. YouGov is now one of the world leaders in political and business information gathering, polling and analysis. It employs over 400 staff on three continents and is listed on the London Stock Exchange. Again – it begs the question on why should Labour should wish to outdo the Conservatives on its own ability to use polling data? One of the polls which has become a toxic meme is how a high proportion of all voters would not mind who provides the NHS services, as long as it’s free at the point of use. However, this is intrinsically linked to other questions. Would you be prepared more in national insurance if it meant the NHS were able to provide a more comprehensive (universal) service? Perhaps Labour would feel so out-of-its-depth in making short-term tactical decisions, if it had a real sense of strategy of where it wished to progress with the National Health Service beyond the natural time course of one or two governments. And a lot depends on which results you decide to report, and how.

Take for example, these findings:

So, arguably, the “evidence” is there, but Labour had a strong sense of its guiding principles and values, it could lead rather than follow. It is indeed correct to state that the costs of renationalising the NHS might be overwhelming, although no accurate costings of this have ever been discussed properly. We do know, however, that the current cost of the NHS reorganisation is in the region of £3bn, but estimates of the actual cost inevitably have to be taken with a pinch of salt, as say the cost of Margaret Thatcher’s funeral. But to use this issue as a wish to stop discussion of this area is lazy, as one of the issues, as indeed as with Thatcher’s funeral, is that is this a sensible use of money compared to how it could be used elsewhere (so called “opportunity cost“)? Some people argue that the marketisation of the NHS has failed, in that any money spent on restoring a state-funded NHS would be money well spent. Restoring a state-funded service would get out of the idea of private companies being driven by maximising their profit margin, and not running a ‘more for less’ approach for delivering a service. Cynics might argue that the cost of restoring a state-run service is peanuts compared to waging a war abroad. Many remain unconvinced about the mantra that economic competition drives up quality, when it is the professional standards of healthcare staff, including doctors, nurses and allied health professionals, which appear to be at the heart of quality. The debate we have just had about the mode of procurement in the NHS was not one any of us as such elected; in other words, it has no mandate. If the Conservatives and the right-wing media appear so pre-occupied about having a referendum next parliament on our membership of the EU, many are (rightly) asking why Ed Miliband cannot ask for a mandate to take sensible decisions about the nature of the NHS. It is a given that there will always be a proportion of services which are outsourced to the private sector, but the question should be ‘how much’. Whilst a full-blown privatisation of the NHS has not happened yet, we have not even had a discussion of how much of the NHS should be outsourced.

And anyway Labour has to ask what really concerns all voters? In Mid Staffs and Cumbria, it is reported that there have been concerns about patient safety, and it may be mere coincidence that Labour failed to convince the voters in both places in the local elections over their offerings. However, there is certainly a ‘debate to be had’, about whether “efficiency savings” in the NHS are justified to produce surpluses in the NHS which get ploughed back into the Treasury (and therefore might be used for international overseas aid rather than frontline care.) Labour equally seems unable to look another ‘white elephant’ in the eye. That is of course the concept of a NHS hospital going bust. Should a NHS Trust which is in financial difficulty be simply allowed to go insolvent after a period of administration, or should the State pump money into it to maintain a local service to people in the community? This requires a fundamental reappraisal of how important “solidarity” and “social democracy” are, in fact, to Labour, and whether it wishes to use its extensive brand loyalty to have a mature, if sobering, discussion of the extent to which it wishes to fund a SOCIALIST National Health Service. Whilst in extremis it can be argued that a nostalgic return to ‘The Spirit of ’45” is not attainable, and is the wrong solution for the wrong times, there is a genuine perception that Labour has lost sight of its founding values. And why has this not been addressed in focus groups? It is well known that, in marketing, if you ask the wrong questions, you ubiquitously get the wrong answers.

If Labour is unsure of its founding core principles and values, Labour might seek to need a mandate to confront these issues, but it is dubious the extent to which it relied on any mandate to implement the Private Finance Initiative, the purchaser-provider split, or NHS Foundation Trusts (whether or not it was responsible for coming up with these policies in the first place). And it should not be afraid to look for a resounding mandate, either. Whilst it might stick its fingers in its ears, and claim it’s nothing to do with them (arguing instead for integrated, “whole person” care), unless these ideological issues are confronted, NHS policy will continue to go down a right-wing path. For example, there is not much further to see GP ‘businesses’ being offered by the private sector, and the NHS pays for them; in this model, GP ‘businesses’ could operate under a standard 5-year contract, using NHS branding, under a ‘franchising’ model like Subway. And “The Tony Blair Dictum” is far from resolved, although currently there are issues more worthy of ‘firefighting’ in service delivery, such as the fiasco over ‘1111’. Labour’s problem is that it does not see the NHS as a ‘vote winner’, in the same way it doesn’t see the plight of disabled citizens experiencing difficulty with their benefits or people feeling genuinely threatened by ‘the bedroom tax’ as a top priority. Whilst Labour is unable to prioritise its issues in a way to align its aspirations with the concerns of the general public, there is no way on Earth it can hope to govern a convincing majority. If Labour wishes to learn a really useful trick from marketing, it could no better than to look at the ‘GAP analysis’ – looking at what the current situation is, and what the expectations of people are, and thinking how to get to a position of what people want. If people actually want a socialist universal, comprehensive NHS, paid for not in a private insurance system, Labour can be expected to work hard for a mandate to deliver this. If it doesn’t, that’s another matter, and it can witter on about whole-person care to its heart’s content. Don’t get me wrong – this work is incredibly impressive, and the Shadow Team have done a lot of work into making it as formidable as it is, but it’s an old cliché: keep up the good work, but please don’t throw the baby out with the bathwater, and stick to your core principles!

We've just had a huge debate about the NHS. It's just a pity that it's been the wrong one.

May 12, 2013 8:26 pm / Leave a Comment

Think of how much time we’ve just all spent, in thinking about the way in which services will be mostly put out for competitive tendering in the National Health Service. One of the first rules in law is that you fight your battles to the hilt, but, at first, you pick the right battles first. This is precisely what Labour appears not to have done. When Harriet Harman recently said on Question Time that the Conservatives are definitely not ‘to be trusted with the NHS’, Harriet curiously did not refer to the battle and war just won by the Conservatives (and Liberal Democrats) over NHS procurement. And yet the public desperately want Labour to stand up for the NHS. One member even suggested that, if Labour gave its unequivocal backing for restoring the NHS, Labour could even find itself with a massive vote winner.

Labour is clearly going through policy strands with a fine tooth comb, looking at, for example, the way in which multinational companies might employ workers at below the national minimum wage; effectively, controlling immigration through a wage policy. It does not appear to have worked out unequivocally whether it would reduce the rate of VAT, meaning possibly that the state borrowing requirement would temporarily increase. But do you see what they all did there? For days, weeks, or even months, we have been subjected to a relentless debate about EU immigration, when most surveys probably place the issue at number ten on the list of voters’ concerns. Unsurprisingly, the economy remains in ‘pole position’, but the ability of Labour to turn the opinion of the public, particularly in the South of England, away from the idea that Labour is ‘fiscally incontinent’ remains unconvincing. Labour is still considered to be the “tax and spend” party, for example, and Miliband appears painfully aware of that. So, when it comes to policy, there seems to be an odd combination of Labour shooting itself in the foot, or completely picking the wrong battles. And then you add in a complete inability to look at elephants in the room. Labour, to state the obvious, has no ability to implement any of its policies, if it is unable to win a General Election, and the confidence of Labour to win an election on its own is reflected accurately in Lord Adonis promoting his book that ‘if he were to form a new Lib-Lab pact, he wouldn’t start from here.‘

The NHS remains pivotal in Labour’s electoral chances, and Labour has been unable to use the resentment over the section 75 NHS regulations to maximise political capital. Why this should have happened in itself is interesting, as Andy Burnham, MP for Leigh, is a more than capable Shadow Secretary of State for Health. One of the issues is an ability to choose the right battle, possibly. Burnham, with some support from the right-wing media and thinktanks, has been banging on about integrated and whole-person care. Whether through conspiracy or cock-up, there will be short-term interest in how integrated care might be delivered. Think about a justification for State spending in the ‘mission impossible’ of implementing a NHS IT system. Why on earth would a right-wing libertarian government promote something which is national? Why on earth should you abort an ethos of ‘bonfire of the QUANGOs’ to introduce the biggest QUANGO in the country, viz NHS England? Whether you’re into conspiracy or cock-up, the integration of financial and medical information (including mental, physical and social care systems) allows for the perfect infrastructure for an insurance-based system. Insurance works on the basis of misrepresentation or non-disclosure to invalidate claims, so ‘big data’ serve a perfect storm for this. It won’t have escaped anybody’s attention that Labour (as indeed the Conservative Party) has been heading towards an insurance-based system for social care, so it does not require a massive ideological leap to think how this could be extended for all care with time. This does not involve any degree of paranoia, please note.

There is overwhelmingly an intellectual depravity in the bereft notion of producing policy through poll results and focus groups. New Labour clearly loved focus groups, with Philip Gould in ‘The Unfinished Revolution’ having devoted much airspace to developing a product in line with customers’ wishes. Of course, the Conservatives have a special affinity for polling organisations themselves, Nadhim Zadawi, in 2000 he co-founded YouGov and on its flotation became its CEO. YouGov is now one of the world leaders in political and business information gathering, polling and analysis. It employs over 400 staff on three continents and is listed on the London Stock Exchange. Again – it begs the question on why should Labour should wish to outdo the Conservatives on its own ability to use polling data? One of the polls which has become a toxic meme is how a high proportion of all voters would not mind who provides the NHS services, as long as it’s free at the point of use. However, this is intrinsically linked to other questions. Would you be prepared more in national insurance if it meant the NHS were able to provide a more comprehensive (universal) service?

It is indeed correct to state that the costs of renationalising the NHS might be overwhelming, although no accurate costings of this have ever been discussed properly. We do know, however, that the current cost of the NHS reorganisation is in the region of £3bn, but estimates of the actual cost inevitably have to be taken with a pinch of salt, as say the cost of Margaret Thatcher’s funeral. But to use this issue as a wish to stop discussion of this area is lazy, as one of the issues, as indeed as with Thatcher’s funeral, is that is this a sensible use of money compared to how it could be used elsewhere (so called “opportunity cost“)? Some people argue that the marketisation of the NHS has failed, in that any money spent on restoring a state-funded NHS would be money well spent. Restoring a state-funded service would get out of the idea of private companies being driven by maximising their profit margin, and not running a ‘more for less’ approach for delivering a service. Cynics might argue that the cost of restoring a state-run service is peanuts compared to waging a war abroad. Many remain unconvinced about the mantra that economic competition drives up quality, when it is the professional standards of healthcare staff, including doctors, nurses and allied health professionals, which appear to be at the heart of quality. The debate we have just had about the mode of procurement in the NHS was not one any of us as such elected; in other words, it has no mandate. If the Conservatives and the right-wing media appear so pre-occupied about having a referendum next parliament on our membership of the EU, many are (rightly) asking why Ed Miliband cannot ask for a mandate to take sensible decisions about the nature of the NHS. It is a given that there will always be a proportion of services which are outsourced to the private sector, but the question should be ‘how much’. Whilst a full-blown privatisation of the NHS has not happened yet, we have not even had a discussion of how much of the NHS should be outsourced.

And anyway Labour has to ask what really concerns all voters? In Mid Staffs and Cumbria, it is reported that there have been concerns about patient safety, and it may be mere coincidence that Labour failed to convince the voters in both places in the local elections over their offerings. However, there is certainly a ‘debate to be had’, about whether “efficiency savings” in the NHS are justified to produce surpluses in the NHS which get ploughed back into the Treasury (and therefore might be used for international overseas aid rather than frontline care.) Labour equally seems unable to look another ‘white elephant’ in the eye. That is of course the concept of a NHS hospital going bust. Should a NHS Trust which is in financial difficulty be simply allowed to go insolvent after a period of administration, or should the State pump money into it to maintain a local service to people in the community? This requires a fundamental reappraisal of how important “solidarity” and “social democracy” are, in fact, to Labour, and whether it wishes to use its extensive brand loyalty to have a mature, if sobering, discussion of the extent to which it wishes to fund a SOCIALIST National Health Service. Whilst in extremis it can be argued that a nostalgic return to ‘The Spirit of ’45” is not attainable, and is the wrong solution for the wrong times, there is a genuine perception that Labour has lost sight of its founding values. And why has this not been addressed in focus groups? It is well known that, in marketing, if you ask the wrong questions, you ubiquitously get the wrong answers.

Labour needs a mandate to confront these issues. And it should not be afraid to look for a resounding mandate, either. Whilst it might stick its fingers in its ears, and claim it’s nothing to do with them (arguing instead for integrated, “whole person” care), unless these ideological issues are confronted, NHS policy will continue to go down a right-wing path. For example, there is not much further to see GP ‘businesses’ being offered by the private sector, and the NHS pays for them; in this model, GP ‘businesses’ could operate under a standard 5-year contract, using NHS branding, under a ‘franchising’ model like Subway. And “The Tony Blair Dictum” is far from resolved, although currently there are issues more worthy of ‘firefighting’ in service delivery, such as the fiasco over ‘1111’. Labour’s problem is that it does not see the NHS as a ‘vote winner’, in the same way it doesn’t see the plight of disabled citizens experiencing difficulty with their benefits or people feeling genuinely threatened by ‘the bedroom tax’ as a top priority. Whilst Labour is unable to prioritise its issues in a way to align its aspirations with the concerns of the general public, there is no way on Earth it can hope to govern a convincing majority. If Labour wishes to learn a really useful trick from marketing, it could no better than to look at the ‘GAP analysis’ – looking at what the current situation is, and what the expectations of people are, and thinking how to get to a position of what people want. If people actually want a socialist universal, comprehensive NHS, paid for not in a private insurance system, Labour can be expected to work hard for a mandate to deliver this. If it doesn’t, that’s another matter, and it can witter on about whole-person care to its heart’s content.

We've just had a huge debate about the NHS. It's just a pity that it's been the wrong one.

May 12, 2013 7:36 pm / Leave a Comment

Think of how much time we’ve just all spent, in thinking about the way in which services will be mostly put out for competitive tendering in the National Health Service. One of the first rules in law is that you fight your battles to the hilt, but, at first, you pick the right battles first. This is precisely what Labour appears not to have done. When Harriet Harman recently said on Question Time that the Conservatives are definitely not ‘to be trusted with the NHS’, Harriet curiously did not refer to the battle and war just won by the Conservatives (and Liberal Democrats) over NHS procurement. And yet the public desperately want Labour to stand up for the NHS. One member even suggested that, if Labour gave its unequivocal backing for restoring the NHS, Labour could even find itself with a massive vote winner.

Labour is clearly going through policy strands with a fine tooth comb, looking at, for example, the way in which multinational companies might employ workers at below the national minimum wage; effectively, controlling immigration through a wage policy. It does not appear to have worked out unequivocally whether it would reduce the rate of VAT, meaning possibly that the state borrowing requirement would temporarily increase. But do you see what they all did there? For days, weeks, or even months, we have been subjected to a relentless debate about EU immigration, when most surveys probably place the issue at number ten on the list of voters’ concerns. Unsurprisingly, the economy remains in ‘pole position’, but the ability of Labour to turn the opinion of the public, particularly in the South of England, away from the idea that Labour is ‘fiscally incontinent’ remains unconvincing. Labour is still considered to be the “tax and spend” party, for example, and Miliband appears painfully aware of that. So, when it comes to policy, there seems to be an odd combination of Labour shooting itself in the foot, or completely picking the wrong battles. And then you add in a complete inability to look at elephants in the room. Labour, to state the obvious, has no ability to implement any of its policies, if it is unable to win a General Election, and the confidence of Labour to win an election on its own is reflected accurately in Lord Adonis promoting his book that ‘if he were to form a new Lib-Lab pact, he wouldn’t start from here.‘

The NHS remains pivotal in Labour’s electoral chances, and Labour has been unable to use the resentment over the section 75 NHS regulations to maximise political capital. Why this should have happened in itself is interesting, as Andy Burnham, MP for Leigh, is a more than capable Shadow Secretary of State for Health. One of the issues is an ability to choose the right battle, possibly. Burnham, with some support from the right-wing media and thinktanks, has been banging on about integrated and whole-person care. Whether through conspiracy or cock-up, there will be short-term interest in how integrated care might be delivered. Think about a justification for State spending in the ‘mission impossible’ of implementing a NHS IT system. Why on earth would a right-wing libertarian government promote something which is national? Why on earth should you abort an ethos of ‘bonfire of the QUANGOs’ to introduce the biggest QUANGO in the country, viz NHS England? Whether you’re into conspiracy or cock-up, the integration of financial and medical information (including mental, physical and social care systems) allows for the perfect infrastructure for an insurance-based system. Insurance works on the basis of misrepresentation or non-disclosure to invalidate claims, so ‘big data’ serve a perfect storm for this. It won’t have escaped anybody’s attention that Labour (as indeed the Conservative Party) has been heading towards an insurance-based system for social care, so it does not require a massive ideological leap to think how this could be extended for all care with time. This does not involve any degree of paranoia, please note.

There is overwhelmingly an intellectual depravity in the bereft notion of producing policy through poll results and focus groups. New Labour clearly loved focus groups, with Philip Gould in ‘The Unfinished Revolution’ having devoted much airspace to developing a product in line with customers’ wishes. Of course, the Conservatives have a special affinity for polling organisations themselves, Nadhim Zadawi, in 2000 he co-founded YouGov and on its flotation became its CEO. YouGov is now one of the world leaders in political and business information gathering, polling and analysis. It employs over 400 staff on three continents and is listed on the London Stock Exchange. Again – it begs the question on why should Labour should wish to outdo the Conservatives on its own ability to use polling data? One of the polls which has become a toxic meme is how a high proportion of all voters would not mind who provides the NHS services, as long as it’s free at the point of use. However, this is intrinsically linked to other questions. Would you be prepared more in national insurance if it meant the NHS were able to provide a more comprehensive (universal) service?

It is indeed correct to state that the costs of renationalising the NHS might be overwhelming, although no accurate costings of this have ever been discussed properly. We do know, however, that the current cost of the NHS reorganisation is in the region of £3bn, but estimates of the actual cost inevitably have to be taken with a pinch of salt, as say the cost of Margaret Thatcher’s funeral. But to use this issue as a wish to stop discussion of this area is lazy, as one of the issues, as indeed as with Thatcher’s funeral, is that is this a sensible use of money compared to how it could be used elsewhere (so called “opportunity cost“)? Some people argue that the marketisation of the NHS has failed, in that any money spent on restoring a state-funded NHS would be money well spent. Restoring a state-funded service would get out of the idea of private companies being driven by maximising their profit margin, and not running a ‘more for less’ approach for delivering a service. Cynics might argue that the cost of restoring a state-run service is peanuts compared to waging a war abroad. Many remain unconvinced about the mantra that economic competition drives up quality, when it is the professional standards of healthcare staff, including doctors, nurses and allied health professionals, which appear to be at the heart of quality. The debate we have just had about the mode of procurement in the NHS was not one any of us as such elected; in other words, it has no mandate. If the Conservatives and the right-wing media appear so pre-occupied about having a referendum next parliament on our membership of the EU, many are (rightly) asking why Ed Miliband cannot ask for a mandate to take sensible decisions about the nature of the NHS. It is a given that there will always be a proportion of services which are outsourced to the private sector, but the question should be ‘how much’. Whilst a full-blown privatisation of the NHS has not happened yet, we have not even had a discussion of how much of the NHS should be outsourced.

And anyway Labour has to ask what really concerns all voters? In Mid Staffs and Cumbria, it is reported that there have been concerns about patient safety, and it may be mere coincidence that Labour failed to convince the voters in both places in the local elections over their offerings. However, there is certainly a ‘debate to be had’, about whether “efficiency savings” in the NHS are justified to produce surpluses in the NHS which get ploughed back into the Treasury (and therefore might be used for international overseas aid rather than frontline care.) Labour equally seems unable to look another ‘white elephant’ in the eye. That is of course the concept of a NHS hospital going bust. Should a NHS Trust which is in financial difficulty be simply allowed to go insolvent after a period of administration, or should the State pump money into it to maintain a local service to people in the community? This requires a fundamental reappraisal of how important “solidarity” and “social democracy” are, in fact, to Labour, and whether it wishes to use its extensive brand loyalty to have a mature, if sobering, discussion of the extent to which it wishes to fund a SOCIALIST National Health Service. Whilst in extremis it can be argued that a nostalgic return to ‘The Spirit of ’45” is not attainable, and is the wrong solution for the wrong times, there is a genuine perception that Labour has lost sight of its founding values. And why has this not been addressed in focus groups? It is well known that, in marketing, if you ask the wrong questions, you ubiquitously get the wrong answers.

Labour needs a mandate to confront these issues. And it should not be afraid to look for a resounding mandate, either. Whilst it might stick its fingers in its ears, and claim it’s nothing to do with them (arguing instead for integrated, “whole person” care), unless these ideological issues are confronted, NHS policy will continue to go down a right-wing path. For example, there is not much further to see GP ‘businesses’ being offered by the private sector, and the NHS pays for them; in this model, GP ‘businesses’ could operate under a standard 5-year contract, using NHS branding, under a ‘franchising’ model like Subway. And “The Tony Blair Dictum” is far from resolved, although currently there are issues more worthy of ‘firefighting’ in service delivery, such as the fiasco over ‘1111’. Labour’s problem is that it does not see the NHS as a ‘vote winner’, in the same way it doesn’t see the plight of disabled citizens experiencing difficulty with their benefits or people feeling genuinely threatened by ‘the bedroom tax’ as a top priority. Whilst Labour is unable to prioritise its issues in a way to align its aspirations with the concerns of the general public, there is no way on Earth it can hope to govern a convincing majority. If Labour wishes to learn a really useful trick from marketing, it could no better than to look at the ‘GAP analysis’ – looking at what the current situation is, and what the expectations of people are, and thinking how to get to a position of what people want. If people actually want a socialist universal, comprehensive NHS, paid for not in a private insurance system, Labour can be expected to work hard for a mandate to deliver this. If it doesn’t, that’s another matter, and it can witter on about whole-person care to its heart’s content.

Lord Owen's NHS (amended duties and powers) Bill: an eight-clause Bill to restore a comprehensive NHS accountable to parliament

January 29, 2013 1:36 am / Leave a Comment

As of early this morning (Tuesday 29 January 2013), the NHA Party and the UK Labour Party seem set to support Lord Owen’s NHS (amended duties and powers) Bill (“the Bill”), as described by Lord Owen himself here, yesterday.

The Health and Social Care Act (2012) ended the Secretary of State’s duty to secure or provide health services throughout the country, a duty that had been in force since 1948. Furthermore, the Act breaks up the universal system that has been effective over sixty years, and provides the NHS trademark for services outsourced to the private sector to maximise the shareholder dividend of those companies.

A major focus of Lord Owen’s Bill is undoubtedly its emphasis, as Lord Owen provides, to “secure a comprehensive, integrated health service”. The Bill in fact contains references to “comprehensive” in clauses 1,5 and 6. The definition of “comprehensive” in the Oxford English Dictionary is indeed a useful starting point, essentially described as “including or dealing with all or nearly all elements or aspects of something“. “Comprehensive” therefore means for most people “all” or “nearly all”, and it’s a matter of interpretation what “nearly” is. This “nearly” aspect has been a slow-burn in policy, for example: “Labour’s national policy forum will debate a draft document on the NHS which contains references to a “largely” comprehensive and “overwhelmingly” free service.”

In March 2011, the NHS published its NHS Constitution, and a leading guiding principle is:

The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief

This non-discriminatory aspect of provision of healthcare therefore emphasises equality.

Colin Leys in the Guardian has previously highlighted the effect of the Health and Social Care Act (2012) in deteriorating the comprehensiveness of the service:

Under the bill the range of what is available for free seems certain to contract further. Commissioning groups will have fixed budgets. The for-profit “support organisations” that are being lined up to do most of the commissioning for them will have a strong incentive to limit costs, and therefore the treatments to be paid for. CCGs also look likely to be free to decide that some treatments recommended by hospital specialists are “unreasonably” expensive, and refuse to pay for them, as health maintenance organisations do in the US.

A core of free NHS services will remain, but they will be of declining quality, because for-profit providers will cherry-pick the most profitable services. NHS hospitals will be left with the more costly work, so staffing levels and standards of care will be forced down and waiting times will get longer. To be sure of getting good healthcare people will increasingly take out private insurance, if they can afford it. At first most people will take out the cheaper insurance plans now on offer that cover just what is no longer free from the NHS, but gradually insurance for most forms of care will become normal. The poor will be left with a limited package of free services of lower quality.

What is available on the NHS should be determined nationally, in a transparent and democratic way, not by unelected local bodies. The bill will allow the secretary of state to deny responsibility when good, comprehensive, free care has become a thing of the past.

There are indications that services are being “scaled back”. For example, there have latterly been reports of impact on hearing services, for example:

NHS hearing services are being scaled back in England, an investigation by campaigners suggests.

Data obtained by Action on Hearing Loss from 128 hospitals found more than 40% had seen cuts in the past 18 months.

In particular, the study found evidence of rises in waiting times and reductions in follow-up care.

The report is the latest in a growing number to have suggested front-line care is being rationed as the health service struggles with finances.

The NHS is in the middle of a £20bn five-year savings drive.

The real question is of course how viable is it to have a totally NHS, which is “comprehensive” and “free-at-the-point-of-use”.

Even in the course of yesterday evening, this tweet of mine received 32 retweets, while most of my thread were (quite rightly) pre-occupied about the BBC Panorama documentary on disabled citizens and employment opportunities.

Prof Allyson Pollock and David Price explain the rationale for this urgent Bill as follows (see QMUL press release):

The Abolition of the democratic and legal basis for the NHS in England

The democratic and legal basis for the NHS in England was abolished by the Health and Social Care Act 2012. The impact of this fundamental change is already being felt, ahead of the shift to the new market system in April 2013.

The Act ended the Secretary of State’s duty to secure or provide health services throughout the country, a duty that had been in force since 1948.

A minister may only be held to account legally for services that he or she is responsible for by law. In future, if we can’t get the health care we need, ministers won’t have to worry about being taken to court on this count, and there will be no Primary Care Trust to put pressure on. This means fewer rights for people in England to get the health care we need – at a time of unprecedented cuts and closures.

The Act breaks up the universal system that has served us for over sixty years, and reduces the NHS to a stream of taxpayer funds and a logo for the use of a range of public and corporate providers of services.

A House of Lords’ bill published this week will reinstate the Secretary of State’s legal duty to provide the NHS in England and the right of all of us in England to comprehensive and integrated health care.

By restoring the legal and democratic basis, the new National Health Service (Amended Duties and Powers) Bill will ensure basic questions about citizens’ rights will continue to be determined democratically, as they should be.

This briefing explains what the government is doing and why an urgent bill to reinstate the NHS in England is required.

What does the government’s Act mean for me?

Cutting free NHS services

When the 2012 Act is implemented, the government will no longer be responsible for providing for our health care needs free of charge. The system of health care which has served all people throughout England for over sixty years is being dismantled and broken up. Instead a range of bodies, including for-profit companies, will decide which services will be freely available and who will receive them.

Currently many NHS services are being transferred to local authorities. They can bring in commercial companies to run them and the 2012 Act provides new charging powers. During the passage of the Health and Social Care Bill last year these services included[1]:

immunization, cancer and cardiovascular screening
mental health care
dental public health
public health
sexual health services
management of drug and alcohol addiction
emergency planning and health protection service
child health services.

Concerns were repeatedly raised during the passage of the Bill that some services would no longer required by law to be provided free of charge. These services included: [2]

Services and facilities for pregnant women, women who are breast-feeding
Services for both younger and older children
Services for the prevention of illness
Care of persons suffering from illness and their after-care
Ambulance services
Services for people with mental illness
Dental public health services
Sexual health services

Putting commercial companies in control

The Act also promotes more marketisation. More and more NHS services are being put out to tender to for-profit companies and taxpayer funds are being given to commercial corporations whilst publicly run health facilities are closed down.

As the 2012 Act is being implemented, corporations will have more say in determining our entitlement to free health services. In future, no single organisation will be responsible in our area for ensuring all our care. And it will no longer be clear who should be held accountable when things go wrong.

Our relationship with our doctor will change when for-profit companies run more services. As a patient we will no longer necessarily come first: how can we feel confident that our doctor is putting us first when he or she is a for-profit company employee?

Privatisation and marketization has increased in advance of the Act.

Some services, including those for the most vulnerable people in society, were last year contracted out to for-profit companies such as Virgin and Serco, which have little or no experience in delivering care. These include services for children with mental health problems and physical disabilities in Devon[3], and community nursing and health visitor services in Surrey[4] and Suffolk[5].

Many NHS hospitals are owned and operated under the expensive private finance initiative, creating serious financial problems for them and putting neighbouring hospitals and services at risk. For-profit companies and investors now control GP practices and other local health services. According to the Financial Times, Virgin already earns around £200 million a year by running more than 100 NHS services nationwide, including GP surgeries.[6] A private company registered in the Virgin Islands now manages the local hospital in Huntingdon, Hinchingbrooke NHS Trust.

The government is manufacturing a financial crisis in the NHS.

It is clear that the government is manufacturing a crisis, reducing the level of services and their quality, and shaking public confidence in the NHS. We are being encouraged to accept the principle that we will in future have to pay privately for services that were once free.

But claims that we can no longer afford the NHS are untrue.

The NHS is not over budget. Last year the NHS budget was underspent and £2 billion was returned to the Treasury.[7] Headline stories about hospital and other health service deficits only mean that resources are unfairly distributed not that the NHS is unaffordable overall.

Government claims that it is protecting the NHS budget are also untrue.

According to the official watchdog, the Statistics Authority: “expenditure on the NHS in real terms was lower in 2011-12 than it was in 2009-10.”[8]

The NHS is being run as if it is in a financial crisis but this crisis is of the government’s making. Current plans for cutting NHS budgets, hospital beds and sacking thousands of vital NHS staff are based on documents drawn up by management consultancy firms including the US company, McKinsey & Co. The policy will lead to closure and hollowing out of public services and the creation of opportunities for an expanded market for private provision and the introduction of user charges.

The policy is fuelling cuts, closures and mergers on a scale that is unparalleled. There is no evidence to support change on this scale nor the unfair distribution of funds[9].

Cuts and closures

In North West London the government plans to cut 25% of beds, and throughout London at least 7 accident and emergency departments will close[10], with further departments under threat. Up to 5600 jobs in North West London will be lost by 2015[11]. Barnet and Chase Farm Hospitals NHS Trust is cutting 208 posts.[12]
In Merseyside, 4000 NHS jobs will go by 2014[13]
In South Yorkshire, Rotherham Hospital is set to lose 750 staff by 2015[14]
In West Suffolk, Serco is planning to cut 137 Community Healthcare jobs.[15]
In Devon and Exeter, the Royal Devon and Exeter NHS Foundation Trust plans to cut 1115 full-time equivalent posts between 2011 and 2014.[16]
In Greater Manchester, there are plans to downgrade Trafford General Hospital’s A&E to urgent care and cuts to intensive care, acute surgery and children’s services. [17] Maternity services have already closed.[18] Salford Royal NHS Foundation Trust plans to cut 750 full-time posts by 2013. [19] Bolton NHS trust is making 500 redundancies.[20]
In Warwickshire, the George Eliot Hospital NHS Trust plans to cut the equivalent of 257 full-time staff between 2010 and 2014.[21]
In Cornwall, Royal Hospital Truro proposed to cut 400 jobs in 2011.[22]
In Portsmouth, Queen Alexandra Hospital cut 700 jobs and shut 3 wards in 2011[23].
Across England, twenty four out of thirty NHS Direct call centres will close[24]
6000 nursing posts have been cut since the coalition came to power in 2010.[25]

Mergers

Hospital mergers reduce services and increase waiting times and travel distances.

Merger with North Tees was followed by closure of A & E in Hartlepool in August 2011[26]
Merger of South London trust is followed by recommendation of closure of Lewisham hospital A&E. [27]
Merger of Queen Mary’s Sidcup NHS Trust (QMS), Queen Elizabeth Hospital NHS Trust (QEH) and Bromley Hospitals NHS Trust (BHT) to create a single hospital on several sites in 2009 was followed by closure of Queen Mary’s A&E and labour unit in 2010.[28]
Merger of Norfolk and Waveney and Suffolk mental health trusts was followed by cuts in beds for acute mental illness and community mental health teams[29]
Barnet and Chase Farm Hospitals NHS trust currently plans a merger which is likely to result in closure of A&E, maternity and paediatric services [30].
Merger resulted in closure of Trafford General Maternity Unit in 2010[31] and A&E is threatened.[32]
Merger with Blackburn Hyndburn and Ribble Valley (BHRV) NHS Trust in 2003 was followed by closure of Burnley A&E in 2008[33] and the paediatric inpatient ward in 2010[34].
Merger resulted in closure of Rochdale Infirmary, Greater Manchester A&E in 2011[35].

Why a Bill is needed to reverse the worst aspects of the Act?

The Health and Social Care Act 2012 must be changed because it removes the democratic and legal basis of the NHS at a time when services are being cut and reconfigured on an unprecedented scale.

The NHS was created in 1948 by a law requiring the secretary of state to fund and provide all medical, dental and nursing care to the whole population on an equitable basis throughout the country. This duty has been abolished.

The government has no mandate for this Act. We did not vote for the abolition of our NHS. Neither was it a part of the coalition agreement. Unlike England, citizens of Scotland, Wales, and Northern Ireland will continue to have a NHS.

The purpose and limitations of the urgent Bill

The proposed legislation restores the legal and democratic basis of the NHS and the citizens’ rights ultimately to hold the Secretary of State to account. It will restore the Secretary of State’s duty to provide the NHS in England and gives him or her ministerial powers of direction and planning in order that the duty can be properly discharged.

Specifically, the Bill will:

reinstate the secretary of state’s duty to provide health services that was formerly contained within sections 1 and 3 of the NHS Act 2006;
subject all NHS bodies and bodies providing services for the NHS to ministerial direction;
repeal the duty of autonomy and restore sufficient ministerial control over provision consistent with the secretary of state’s overarching duty to provide health services to the whole of England; and
give Monitor an objective, so that its purpose is to help deliver the NHS.

The Bill will not require further reorganization when it is passed.

Allyson M Pollock (Professor of Public health research and policy,
David Price (Senior Research Fellow)

Global health, policy and innovation unit
Centre for Primary Care and Public Health
Queen Mary, University of London
58 Turner St, London E1 2AB and R

[1] Pollock AM, Price, DP, Roderick, P. How the Health and Social care Bill2011 would end entitlement to comprehensive health care in England

January 26, 2012 DOI:10.1016/S0140- 6736(12)60119-6

[2] Pollock AM, Price D, Roderick P. Health an social care Bill 2011: a legal basis for charging and providing fewer health services to people in England. BMJ 2012;344:1729- 82

[3] http://www.guardian.co.uk/society/2012/jul/12/virgin-care-children-nhs-devon

[4] http://www.telegraph.co.uk/health/healthnews/9176733/NHS-patients-to-be-treated-by-Virgin-Care-in-500m-deal.html

[5] http://www.bbc.co.uk/news/uk-england-suffolk-20395749

[6] http://www.ft.com/cms/s/0/087158f6-3f0a-11e2-9214-00144feabdc0.html#axzz2IsoYpv5t

[7] Department of Health: Securing the future financial sustainability of the NHS, Sixteenth Report of Session 2012–13, House of Commons, Committee of Public Accounts http://www.publications.parliament.uk/pa/cm201213/cmselect/cmpubacc/389/389.pdf

[8] Andrew Dilnot, (Chair of the UK Statistics Authority) Letter to Right Hon Jeremy Hunt MP, dated 4^th December 2012, http://www.statisticsauthority.gov.uk

[9] ‘Can governments do it better? Merger mania and hospital outcomes in the English NHS’, M Gaynor, M Laudicella and C Propper, CMPO working paper 12/281 http://www.bristol.ac.uk/cmpo/publications/papers/2012/wp281.pdf

[10] http://www.dailymail.co.uk/news/article-2200339/NHS-Cuts–Savage-consequences-revealed-pensioner-waits-6-hours-ambulance.html

[11] http://www.healthemergency.org.uk/breakingnews.php Tuesday 23rd October 2012

[12] http://www.enfield-today.co.uk/News.cfm?id=43000&headline=Alarm%20over%20job%20cuts%20at%20hospital

[13] http://www.liverpooldailypost.co.uk/liverpool-news/regional-news/2012/01/19/exclusive-merseyside-nhs-staff-cuts-to-see-4-001-jobs-go-by-2014-99623-30150190

[14] http://www.bbc.co.uk/news/uk-england-south-yorkshire-20092315

[15] http://www.nursingtimes.net/nursing-practice/clinical-zones/district-and-community-nursing/serco-plans-to-cut-137-community-posts-in-suffolk/5052039.article

[16] http://falseeconomy.org.uk/blog/more-than-50k-nhs-job-losses

[17] http://www.manchestereveningnews.co.uk/news/health/dont-axe-trafford-ae-before-799985

[18] http://www.guardian.co.uk/politics/2007/aug/25/uk.health

[19] http://falseeconomy.org.uk/cuts/item/salford-royal-nhs-job-cuts

[20] http://www.bbc.co.uk/news/uk-england-manchester-20319241

[21] http://falseeconomy.org.uk/cuts/item/george-eliot-hospital-job-cuts

[22] http://www.truropeople.co.uk/groups/trurohealth/400-Jobs-Cut-Truro-Royal-Cornwall-Hospital/story-10908019-detail/story.html

[23] http://www.bbc.co.uk/news/uk-england-hampshire-13126925

[24] http://www.dailymail.co.uk/health/article-2230584/NHS-Direct-close-24-30-centres-claims-union.html

[25] http://www.independent.co.uk/life-style/health-and-families/health-news/fears-for-patient-safety-as-60000-nhs-jobs-face-the-axe-8307270.html

[26] http://www.hartlepoolmail.co.uk/news/local/a_e_decision_flawed_claim_1_3879562

[27] http://www.independent.co.uk/life-style/health-and-families/health-news/debtridden-nhs-trust-to-be-scrapped-8231436.html

[28] http://www.hsj.co.uk/acute-care/nhs-london-revives-queen-marys-sidcup-closure-plans-amid-patient-safety-concerns/5019638.article

[29]http://www.eadt.co.uk/news/suffolk_mental_health_trust_to_slash_inpatient_bed_numbers_1_1668405

[30] http://www.telegraph.co.uk/news/politics/8756245/Government-to-merge-Chase-Farm-Hospital-which-David-Cameron-vowed-to-save.html

[31] http://nhsfightback.org/2013/01/03/hospitals-across-greater-manchester-under-threat/

[32] http://www.manchestereveningnews.co.uk/news/health/trafford-health-trust-to-merge-with-neighbours-866605

[33] http://www.dailymail.co.uk/news/article-2207274/A-E-closures-Secret-report-reveals-lives-risk-sweeping-plans-close-25-casualty-units.html

[34]http://www.lancashiretelegraph.co.uk/news/burnley/9016530.Burnley_s_children_ward_to_stay_in_Blackburn/

[35] http://www.manchestereveningnews.co.uk/news/local-news/last-chance-to-save-rochdale-infirmary-679318

Lord Owen’s Bill is proposed as below

National Health Service (Amended Duties and Powers) Bill

A

BILL

TO

Re-establish the Secretary of State’s legal duty as to the National Health Service in England, QUANGOS and related bodies.

BE IT ENACTED by the Queen’s most Excellent Majesty, by and with the advice and consent of the Lords Spiritual and Temporal, and Commons, in this present

Parliament assembled, and by the authority of the same, as follows:—

1 Secretary of State’s duties to promote and provide a comprehensive and integrated health service

For section 1 of the National Health Service Act 2006 (Secretary of State’s duty to promote comprehensive health service) substitute:

“1 Secretary of State’s duty as to the health service

(1) It shall be the duty of the Secretary of State to promote in England a comprehensive and integrated health service designed to secure improvement –

(a) in the physical and mental health of the people of England, and

(b) in the prevention, diagnosis and treatment of illness,

and for that purpose to provide or secure the effective provision of services in accordance with this Act.

(2) The services so provided must be free of charge except in so far as the making and recovery of charges is expressly provided for by or under any enactment, whenever passed.

(3) The services provided pursuant to this Act and to the Health and Social Care Act 2012, howsoever or by whomsoever provided, secured or arranged, shall be deemed to be provided in furtherance of the duty to provide or secure effective provision of services under subsection (1).”

2 Abolition of the duties of autonomy

Section 1D and section 13F of the National Health Service Act 2006 (duties as to promoting autonomy) are repealed.

3 Concurrent duty of and commissioning by the NHS Commissioning Board

(1) Section 1H(2) of the National Health Service Act 2006 is repealed.

(2) In section 1H(3) of that Act, for “For the purpose of discharging that duty,” substitute “For the purpose of furthering the duty of the Secretary of State under section 1(1),”.

4 Secretary of State’s duty as to provision of certain services

(1) Section 3 of the National Health Service Act 2006 is amended as follows.

(2) Before subsection (1) insert—

“(Z1) The Secretary of State must provide or secure the effective provision

throughout England, to such extent as he considers necessary to meet all reasonable requirements, the accommodation, services and facilities set out in subsection (1)(a)-(f).”

(3) In subsection (1), before “A”, insert “For that purpose,”.

5 Power of directions to QUANGOs and other bodies

(1) The Secretary of State may direct any of the bodies mentioned in subsection (2) to exercise any of his functions relating to the health service which are specified in the directions, and may also give directions to any such body about its exercise of any functions or about its provision of services under arrangements referred to in subsection 2(h).

(2) The bodies are—

(a) the National Health Service Commissioning Board
(b) a clinical commissioning group,
(c) a Special Health Authority,
(d) an NHS trust,
(e) an NHS foundation trust,
(f) the National Institute for Health and Care Excellence,
(g) the Health and Social Care Information Centre, and
(h) any other body or person providing services in pursuance of arrangements made—
(i) by the Secretary of State under section 12,
(ii) by the Board or a clinical commissioning group under section 3, 3A, 3B or 4 or Schedule 1,
(iii) by a local authority for the purpose of the exercise of its functions under or by virtue of section 2B or 6C(1) or Schedule 1, or
(iv) by the Board, a clinical commissioning group or a local authority by virtue of section 7A of the National Health Service Act 2006.

(3) In exercising his power under subsection (1), the Secretary of State must have regard to the desirability, so far as consistent with the interests of the health service and relevant to the exercise of the power in all the circumstances—

(a) of protecting and promoting the health of patients and the public;

(b) of any of the bodies mentioned in subsection (2) being free, in exercising its functions or providing services in accordance with its duties and powers, to do so in the manner that it considers best calculated to promote the comprehensive and integrated service referred to in section 1(1) of the National Health Service Act 2006; and

(c) of ensuring cooperation between the bodies mentioned in subsection (2) in the exercise of their functions or provision of services.

(4) If, in having regard to the desirability of the matters referred to in subsection (3) the Secretary of State considers that there is a conflict between those matters and the discharge of his duties under section 1 of the National Health Service Act 2006, he must give priority to the duties under that section.

6 Monitor

(1) The Health and Social Care Act 2012 is amended as follows.

(2) After section 61 insert—

“61A Monitor’s objective

(1) The objective of Monitor is to contribute to the achievement of a comprehensive and integrated health service in England through the exercise of its functions.

(2) In exercising its main duty and other functions Monitor must act in accordance with that objective and in a manner consistent with the performance by the Secretary of State of his duties contained in sections 1 and 3 of the National Health Service Act 2006.”

(3) Section 62(9) is repealed.”

7 Interpretation

Expressions used in this Act which are also used in the National Health Service Act 2006 and in the Health and Social Care Act 2012 shall have the same meanings as the meanings given to those expressions under those Acts.

8 Short title, commencement and extent

(1) This Act may be cited as the National Health Service (Amended Duties and Powers) Act 2013.

(2) This Act shall come into force on the day on which it is passed.

(3) This Act extends to England.

How “comprehensive” is the NHS? Or “Something’s gotta give”?

January 14, 2013 11:19 am / Leave a Comment

Marilyn Monroe

Many in the discussion would wish you to concentrate on the phrase, “free-at-the-point-of-use”. This is the idea that you a patient does not pay for any treatment.

Many also do not understand the Health and Social Care Act (2012). There are many in the social media at large who feel that the NHS needs to face change in improving the service, and indeed point to crises within the NHS as examples of a failing service. It is critical that the NHS can learn from its mistakes, in terms of its operations, strategy and leadership. However, the Act’s primary purpose is not about that. I simply do not understand why the media, and notably the BBC, have been ‘asleep on the job’, in explaining what these £2bn reforms were about. The most common explanation is that the Act is incomprehensible. As a law student, it is perfectly comprehensible, but I would say that? The Act abolishes a number of important national authorities, such as the National Patient Safety Agency and the Health Protection Authority, but it legislates for a much greater number of private companies to do NHS functions in the name of the NHS. This means that ‘market forces’ can lead to distortions in provisions of healthcare, determined by the individual business plans of the companies involved. It is therefore a “supplier-led market”. In the high street, neoliberal forces have seen less profitable sectors such as immigration, housing and asylum, struggling compared to their City counterparts, corporate finance and the such like. Therefore, the critical issue is how “comprehensive” the NHS is.

On top of this, it is impossible to ignore the impact of the drive for ‘efficiency savings’. In 2009, Sir David Nicholson was reported of requiring such savings as below:

NHS trusts will have to deliver between £15 billion and £20 billion in efficiency savings over three years from 2011 to 2014, David Nicholson, the NHS chief executive, told health service finance directors in a speech delivered behind closed doors.

The steep cuts would be equivalent to up to six per cent of the current NHS budget.

Health trusts which fail to deliver the required savings could face tough new penalties following a review by the Department of Health of its enforcement regime.

The definition of “comprehensive” in the Oxford English Dictionary is indeed a useful starting point, essentially described as “including or dealing with all or nearly all elements or aspects of something“:

Definition of “comprehensive” in the OED

“Comprehensive” therefore means for most people “all” or “nearly all”, and it’s a matter of interpretation what “nearly” is. This “nearly” aspect has been a slow-burn in policy, for example: “Labour’s national policy forum will debate a draft document on the NHS which contains references to a “largely” comprehensive and “overwhelmingly” free service.” In March 2011, the NHS published its NHS Constitution, and a leading guiding principle is:

The NHS provides a comprehensive service, available to all irrespective of gender, race, disability, age, sexual orientation, religion or belief

This non-discriminatory aspect of provision of healthcare therefore emphasises equality.

It is therefore disingenious that a campaigning issue that individuals maintain that, after implementation of these costly reforms, that the NHS will still be ‘free-at-the-point-of-use’, as that ignores the comprehensive point. Colin Leys in the Guardian has already highlighted this as an issue in the Guardian:

Under the bill the range of what is available for free seems certain to contract further. Commissioning groups will have fixed budgets. The for-profit “support organisations” that are being lined up to do most of the commissioning for them will have a strong incentive to limit costs, and therefore the treatments to be paid for. CCGs also look likely to be free to decide that some treatments recommended by hospital specialists are “unreasonably” expensive, and refuse to pay for them, as health maintenance organisations do in the US.

A core of free NHS services will remain, but they will be of declining quality, because for-profit providers will cherry-pick the most profitable services. NHS hospitals will be left with the more costly work, so staffing levels and standards of care will be forced down and waiting times will get longer. To be sure of getting good healthcare people will increasingly take out private insurance, if they can afford it. At first most people will take out the cheaper insurance plans now on offer that cover just what is no longer free from the NHS, but gradually insurance for most forms of care will become normal. The poor will be left with a limited package of free services of lower quality.

What is available on the NHS should be determined nationally, in a transparent and democratic way, not by unelected local bodies. The bill will allow the secretary of state to deny responsibility when good, comprehensive, free care has become a thing of the past.

There are indications that services are being “scaled back”. For example, there have latterly been reports of impact on hearing services, for example:

NHS hearing services are being scaled back in England, an investigation by campaigners suggests.

Data obtained by Action on Hearing Loss from 128 hospitals found more than 40% had seen cuts in the past 18 months.

In particular, the study found evidence of rises in waiting times and reductions in follow-up care.

The report is the latest in a growing number to have suggested front-line care is being rationed as the health service struggles with finances.

The NHS is in the middle of a £20bn five-year savings drive.

The political question is, of course, whether the public accepts the need to ‘scale back’ these services and doesn’t care about the service being entirely comprehensive; or whether Labour (or indeed any party) should simply give up on an inspiration for totality in the service. A film once starred Marilyn Monroe entitled “Something’s Gotta Give”, and now that the first major step has been taken in ‘liberalising’ the NHS to any qualified provider, it is perhaps more necessary than ever to admit there is no guarantee at all on the NHS provision being close to “comprehensive”, unless the NHS Commissioning Board gives clear and precise details which services have been cut and where. This is going to be increasingly significant as a mature discussion about rationing gathers momentum too.

Above all, it seems now essential that local respondents are allowed to offer feedback into this clinical decision process, for example as demonstrated recently in the Lewisham situation, otherwise localism is a complete farce.