Despite the rhetoric of ‘taking back control’ of our NHS, the government’s leaked White Paper does not spell an end to profiteering, argues Caitlin Southern
The NHS reform White Paper leaked earlier this month has been both lauded as bringing an end to privatisation within the health service in England and decried as preparing it for yet more sell-offs. One thing the Covid-19 pandemic has highlighted is strong support for the removal of privatisation from the NHS, as it has been shown that it is best placed to deliver the mass health campaigns that we need.
The success of the vaccine rollout coordinated by the public sector, compared to the absolute shambles of the privately administered test and trace and PPE procurement scandals, demonstrates that the interests of the population are best served by a system designed around addressing needs rather than generating profits.
Privatisation in disguise?
Campaign group Keep Our NHS Public (KONP) have however raised concerns about the impact of the proposed reforms, in particular the decision to have every area of England under the control of an Integrated Care Service (ICS) that will allow for joined up care but may also mean that services can be sold off more completely than ever before.
At present, ICSs are voluntary rather than legislatively defined organisations, something this White Paper seeks to address in order to allow them to effectively manage patient outcomes across all health and social care settings within their geographically defined area. The efficiency drive at the heart of this legislation suggests that, rather than allowing the health service to run at a financial loss if it supports the public good, it will be expected to run as cheaply as possible, if not at a profit.
The emphasis on integration does not extend beyond the realm of health and social care into a fully holistic approach that would tackle such contributory factors as poverty and unsuitable housing on health outcomes, and how people use and interact with the health services.
The White Paper states that it is not committed to maintaining one overarching body, but that many different bodies will be needed in order to further the drive towards excellence, reflecting the multifaceted nature of the issues causing and maintaining ill health nationally. That ICSs will be able, and even encouraged, to delegate provision to other providers suggests that the system is going to retain much of the existing privatisation that currently blights the health service.
While admitting that this integration has not always been a success, the Paper states that pushing further forward with it in conjunction with the NHS Long Term Plan will help to remove the obstacles that are hindering it.
What’s not said
The ‘Triple Aim’ of this restructure is to achieve better care for all patients, better health and wellbeing for everyone and the sustainable use of NHS resources. It is however consistently vague on exactly how this is to be achieved, which may be necessary considering the wide range of circumstances across the country, but without this clarity it is difficult to know what is being considered for implementation.
The plans include the creation of joint committees to break down barriers to collaborative interagency interventions, reducing both financial costs and legal risks currently posed by workaround systems. Whether this streamlining approach is best in practice for patient care and confidentiality, as well as for official accountability, remains to be seen.
These joint committees would not be restricted to NHS bodies but would be allowed to include outside representation. Although not directly referred to, this could mean that there would be no provision to exclude private care providers from these committees and the decisions that they make.
While heavily emphasising patient choice, the document is vague on how this is to be achieved, particularly when the ICS model becomes the only one available, meaning that the option would be for patients to use one of these services or turn to the private sector. That the legislation allows for the Any Qualified Provider (AQP) system to remain in place suggests that even if further privatisation is slowed or prevented, that which already exists will remain in place.
The Paper repeatedly emphasises the need to remove excess bureaucracy in order to allow the integration and streamlining of care, and the use of more individual discretion in which procurement systems to use. It does not however mention who will decide what constitutes ‘excess bureaucracy’, or what framework they will be using.
While the Secretary of State will gain more direct control over the NHS, this is at the expense of the people and organisations already in charge, who may be more likely to understand how to run a comprehensive health service than a government minister. It also stresses incorporating more flexibility into systems to allow for more rapid necessary changes, although this could be interpreted as allowing a more slapdash, less considered approach to what would be very important changes in the delivery of services.
It's still a Tory agenda
The admission that competition is not necessarily the best way to drive improvements is a marked deviation from previous legislation, particularly the 2012 Health and Social Care Act, and is a sign perhaps that popular support for the NHS and opposition to privatisation is having an impact on the government. However, until there is further clarification it might just mean that contracts are handed to private companies without the rigmarole of the tendering process, leaving public provision frozen out of the system.
The procurement of non-clinical services is to remain bound by Cabinet Office rules. So, while the frontlines may not be privatised, it is likely that the creeping sell-off of support services will continue unabated. The recognition that running a large-scale health service requires a more invested approach than that envisioned by the 2012 Act is a step forward, but the commitment to retaining competitive tendering where it can be considered to provide value is an indication that this legislation will not hurry the end of privatisation in the NHS.
A worrying clause is the ability of ministers to intervene at any stage of a debate over restructuring. This would allow them to circumvent protest campaigns to save local services that have been effective in preventing the closure of several A&E departments and local hospitals. With this freedom to interfere, the minister can make the decision before it becomes well-known enough to provoke a response, allowing them to ‘streamline’ services into the ground.
The granting of sweeping powers to the Secretary of State for Health and Social Care to remove certain professions from regulation, or to dispense with regulatory bodies when they are deemed to be no longer useful, may provide ‘efficiency savings’ but could be exploited for political gain or to cow militant sections of the workforce.
The NHS is not saved
Overall, the proposed legislation is the kind of top-down reorganisation that it claims to want to avoid. It brings the NHS more under the direct control of the Secretary of State for Health and Social Care but makes very little provision to restrict or remove private sector providers and influence. The framing of ICSs in an exclusively positive light masks the very real concerns of health campaigners that they will lead to less accountability, not more.
While not directly specifying that it will open the door to ever more privatisation, this legislation, in addition to being vague enough to allow multiple interpretations, certainly doesn’t mean that our NHS is safe in the hands of this government.
As with every announcement we have seen, this White Paper provides more, not less, obfuscation in regards to the future of the health service, and that questions of funding, staffing and conditions will not be solved by the proposed reforms. It must be openly and publicly scrutinised and debated in order to influence it in the direction of providing the best care possible, rather than using it as a cash cow to line the pockets of the superrich contacts of the Conservative Party.
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