Monday 1 April 2013

How The NHS Ends

In the Telegraph, let the reader understand, Max Pemberton writes:

Today is a landmark in the history of the NHS. I have no doubt that social historians will look back and define events in relation to this day; we will come to view things as pre- or post-April 1 2013, in the same way that we currently think of before or after the establishment of the NHS. Today the Health And Social Care Act – in other words, the Coalition’s highly controversial NHS reforms – comes into effect. So how will things change for those who rely on the NHS?

It will not be obvious initially. People will get sick, see their GPs, be referred to specialists, be admitted to hospital or discharged, have blood tests and X-rays, and book appointments with physiotherapists and speech therapists, etc. There will be births and deaths. But, beneath the surface there will have been a dramatic shift in the way that healthcare is being delivered. Its impact should not be underestimated.

Preparations began nearly a year ago, when the Bill became law. As a result, primary care trusts (PCTs) began to disband and hand over power to new clinical commissioning groups (CCGs). As of today CCGs are responsible for commissioning the work – that is to say, treatment – undertaken in the name of the NHS. They will be responsible for organising and paying for care, and deciding who will provide it. For the first time in NHS history, the majority of treatments will be put out to tender: private organisations will be competing to win contracts to provide NHS healthcare.

When the original legislation was passed, there was a clause – Section 75 – that stated that the Government would issue further details on the regulations governing private sector involvement in NHS care at an unspecified date. Those of us who attempted to draw attention to this vital lack of clarification were dismissed as paranoid conspiracy theorists, convinced that rampant privatisation of the NHS was imminent.

But the NHS reform Bill, as first published, was like a jigsaw puzzle with crucial pieces missing, the pieces that would reveal exactly what was being planned. It wasn’t until a few weeks before the law came into effect that those missing pieces became available, when the Health Secretary, Jeremy Hunt, quietly announced the new regulations and attempts were made to push them through parliament. What was now clear was that the regulations effectively forced CCGs to put all services out to tender to the private sector and forbade them to favour the NHS as the provider.

After a public outcry and criticism from the House of Lords at the way the Government had slipped in the Section 75 regulations at the eleventh hour, Hunt had them hastily rewritten. But most experts agree that there was no meaningful change. GPs are allowed to keep some services within the NHS, but only in particular circumstances, such as when no private sector provider comes forward to bid. Everything else is up for grabs. It will take time for this change to slowly spread throughout our healthcare system, but it will.

And we should all be worried. Competition on a small scale already exists in the NHS for certain services, such as breast-cancer screening, physiotherapy and rehabilitation, where these contracts have been put out to tender. I have seen first-hand what it can result in: the bureaucracy, the waste of time and resources, as bids are entered, assessed and contracts issued. I have seen, too, the way that services are, invariably, awarded to the lowest bidder regardless of quality, and I have seen how organisations that win these contracts will maximise profits by employing under-trained, cheaper staff, and replacing doctors with nurses, and nurses with auxiliaries.

Last month I was working in a drugs service in the Home Counties. Some agencies, such as those providing drugs and alcohol support services, were opened up for competition by Labour years ago. This particular service was taken over by a non-NHS organisation last year which made a bid considerably lower than what it was then costing the NHS to run it. They did this by reducing the medical input and replacing the majority of nurses with “drugs workers”, many of whom were dedicated and thoughtful, but were not medically trained.

This organisation is only paid for addicts whom they successfully wean off heroin. It receives £3,000 per patient if they abstain for three months, then a further £5,000 if they are still drugs-free a year later. So each patient is worth about £8,000 to the organisation – but only if they stay off heroin. And this is at the root of the problem. I saw a homeless patient who had had several failed attempts at detoxing. He was injecting five bags of heroin a day (about £50 worth). He was incredibly frail and I knew that if he continued, he would soon be dead. To make matters worse, he was injecting into his groin because he had no usable veins left in his arm, running the risk of an infection that can result in amputation of the leg.

I reasoned that although it was unlikely we would cure him of his addiction easily, it was worth trying to engage him in treatment and get him on a prescription for methadone. We would be able to reduce the amount of heroin he needed to take – this, in turn would reduce the amount of crime he committed, the number of needles left lying around, the frequency of injecting. He might even stop using heroin altogether and we could maintain him on methadone while we tried to help him get his life together.

The manager of the clinic, however, was clear: they wouldn’t get paid for this approach as he wouldn’t be regarded as detoxed. Discharging him back on to the streets was the solution. I was horrified: if I discharged him from the service, we were sending him to certain death. There was no NHS service to refer him to because this organisation had taken over the entire contract for drug services in the area. I was staggered that there was no NHS help available to this man. This is just one example of what happens when services go out to tender.

You might think that, well, you’re not a drug addict so why does this matter? This will never affect you. But you’d be wrong. From today, this is the model that is being rolled out across the whole of the NHS. So, say for example you need a knee replacement. The provider commissioned to deliver this by your local CCG will have stipulated in the contract what work it will undertake and how much it will get paid. This is fine if you’re a straightforward case. They do the operation, you’re discharged and they are paid the set fee. But what happens if your knee operation is more complicated?

What if your knee joint has twisted and is now deformed (it does happen), which means the surgeon has to avoid damaging the nerves that run down your leg? All of a sudden, the provider won’t turn such a tidy profit on your knee replacement. This is outside of the terms of their contract. So they reject you and discharge you back to the care of your GP. And what then? There’s no longer an NHS to pick you up because this private organisation has taken over knee operations in your area. So where do you go? Suddenly my heroin-addicted patient being told there’s nothing anyone can do doesn’t seem so far removed from your own situation.

In the new NHS, everything will be about payment by results, because this is all the private contractors are interested in. All “clinical encounters” have to have an easily definable, objectively measurable end point. But what about chronic conditions? Or treatments where the chances of success are low and complications high? This is what saddens me: what were once the NHS’s strengths – resources, expertise and the united focus on the patient – are being replaced by a fragmented and atomised service, bound not by a duty of care but by a contract and driven, not by what is best for the patient, but by the cost of the encounter. It will be a slow, insidious creep but it’s coming. Be prepared. This is the way the NHS ends: not with a bang but a whimper.

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