With opposition to the Health and Social Care Bill having reached new heights, we must look behind the rhetoric and remember basic principles. The most important point to remember is that the NHS exists to provide the best possible, affordable treatment to patients. People are living longer, largely because of medical successes. Health is poorer in old age. The cost of providing even treatment of today’s standard to everyone is therefore going to grow inexorably in real terms. Rising healthcare expenditure is further fuelled by genuine medical progress, which often involves ever more sophisticated and costly treatment. No country can truly provide the best healthcare to all its citizens. Every Government would like to be able to do so and every opposition party tries to make political capital out of the impossibility of complete success.
The UK has certain highly creditable ideals about which all major British political parties agree: that healthcare on the NHS should generally be free, that all NHS patients should be treated as equally as possible and that all illnesses should be covered. Even these principles are already subject to exceptions. Charges can be payable to dentists and opticians and for prescription drugs. A person who lives in a remote rural area cannot expect to receive an ambulance as quickly as someone who lives close to an ambulance station. Illnesses may not be effectively treated if NICE has deemed necessary drugs too expensive.
In the light of the need to control NHS expenditure it is vitally important that the NHS should run as efficiently as possible. An organisation as large as the NHS, which is on some measures the largest employer inEurope, cannot help but be burdened by some inappropriate bureaucracy and inefficiencies. The fact that the NHS is in the Public sector intensifies the risk.
All political parties accept that the NHS needs to become more efficient. However, they have differing views about how to achieve the goal. Conservatives believe in the adaptation of free market principles to encourage the NHS to provide what patients and medical professionals want. The Labour Party strives to control the NHS through a management structure designed to serve the public interest. Liberal Democrats place emphasis on statutory safeguards designed to ensure fairness, the availability of services and accountability. The approaches of the three main parties are ideologically different and will never be fully compatible, even though the desired end results are largely the same.
The Health and Social Care Bill began as a carefully drafted drive to modernise the NHS by the adoption of specific principles. Other political parties have lacked the parliamentary votes to alter the thrust of the Bill. They have instead negotiated Government support for an ever growing raft of amendments that typically enshrine in legislation points that the Government believes would have arisen naturally as a result of the implementation of the Bill. These amendments do not alter the essence of the Bill but they make it harder to understand and implement. Some are to be welcomed but many dilute the message of the Bill and confuse the clarity of the intentions behind it.
My reasons for supporting the Bill have remained unchanged since it was first introduced to Parliament. The features that I most like are:
- Reducing layers and numbers of “middle managers”. Action of this type generally increases the efficiency of large organisations.
- Getting decisions taken at the lowest sensible level so that they are made by the people with the most relevant understanding and experience.
- Aligning the interest of Government, patients, medical professionals and managers as far as possible, by having real clinical targets and concentrating power in the hands of medical professionals.
- Judging the performance of the NHS in terms of outcomes for patients.
- Arranging rewards, whether financial (e.g. profits, pay, money for investment) or personal (e.g. promotion), to reflect success in providing the best affordable treatment. For example, a private company will only be able to make a profit from the NHS if no other provider (including non-profit organisations and charities) can supply a better service at the same price.
- Independence from day-to-day political interference.
The NHS is too important for decisions to be ruled by emotion. Yet public debate has been at a disappointingly low level, hindered by bias. The Labour Party is stoking concern over conspiracy theories and encouraging inaccurate media coverage. Liberal Democrats, particularly in the House of Lords, are still seeking to amend the Bill without opposing it. The Conservative Party is failing to get its message across to medical professionals and the Public.
The Government will not be deflected by opposition because they believe, rightly in my opinion, that they are fighting a just cause. They take comfort that medical professionals have been wrong in their attitude to healthcare management on many occasions in the history of the NHS. For example, the BMA opposed the creation of the NHS shortly after World War II and likened Nye Bevan to Hitler.
A number of misconceptions are being put forward by opponents of the Bill:
- A claim that profit will be put before patients. This allegation is the opposite of what the Bill says. The overriding duty of the NHS is to serve patients. It will be illegal to award contracts in a way that is expected to further profit at the expense of patients.
- A suggestion that private companies will benefit inappropriately. In fact, they will only gain when they can contribute to a better outcome for patients.
- Comment implying that the Government wants 49% of hospital beds and theatre time to go to private patients. This interpretation of the Bill is scaremongering. If all private hospitals closed and all their business was undertaken by NHS hospitals, private patients would only represent 11% of NHS hospital work. The 49% cap is a safeguard applying to individual hospitals and is unlikely to restrict non-NHS income frequently, if ever. No NHS hospital currently comes anywhere near the 49% cap. Owing to other provisions in the Bill none ever will unless NHS patients are expected to benefit in the circumstances applying at the hospitals in question.
- Statements that private companies will cream off profitable work leaving difficult cases to the NHS. The Law will be broken if contracts to private companies are lucrative enough for patients as a whole not to benefit.
- Some Labour supporters and media commentators seem to think that the Bill does not mean what it says. This view is strange since the Law on the NHS can be enforced in the Courts just as in any other field.
- Some commentators are suggesting that the Government is being unreasonable in excluding particular groups such as the BMA from certain talks about the implementation of the Bill once passed. In fact, the excluded groups have said that they firmly oppose the Bill and have appeared not to wish to help it forward constructively. The subject matter to be discussed in the talks is therefore in a category where the excluded parties are unlikely to make a contribution.
Parliamentary debate has occurred and is nearing an end. The reality is that the Bill is going to become Law. If the NHS suffers because medical professionals will not cooperate with the Government, the blame cannot all be laid at Andrew Lansley’s door. A few months can be a very long time in politics. Was Nye Bevin right or wrong when he called the BMA a “small body of politically poisoned people” who had decided “to fight the Health Act itself and to stir up as much emotion as they can in the profession.”?