Let the market rule

So, the NHS in London is set to be hacked about all over again. The graphic here shows the proposals for reconfiguration of Primary Care Trusts in London. There’s no partnership working with trade unions here, of course, and no consultation with the public. The unelected NHS London meets with unelected Chief Executives, and they decide how to carve up healthcare. The direction of travel is determined by a Government run in the interests of big business, but Ministers hide behind the excuse that decisions are taken at local level.

There’s a difference between this and previous reorganisations, though. This one is about fragmentation of the NHS and the outsourcing of healthcare on a scale that has not been seen before.

The rhetoric is about ‘strengthening commissioning’. That means the further separation of commissioners (who buy health care) and providers (the nurses, physiotherapists, speech therapists and so on who sell health care). Commissioners can buy services from anywhere, and a central selection criterion will be ‘value for money’. This means that bidders will be under enormous pressure to cut the cost (and therefore the clinical quality) of the services they provide. Private sector companies have an advantage here – they can whack in loss leader bids, and don’t need to have any expertise or any staff in post in order to win the contract.

Providers are mostly NHS workers at the moment, but that’s changing rapidly. Darzi’s plans – eagerly embraced by NHS London – are about growing rivals. Social enterprise companies, a stepping stone towards out and out privatisation, are being heavily promoted. Private sector companies like Richard Branson’s Virgin are well aware of the hefty profits to be made, and already muscling in on the NHS.

The chart shows the growing number of ‘APOs’ (autonomous provider organisations) – effectively stand alone small businesses, competing on the open market with anyone who wants to sell healthcare. APOs have NHS status on a purely temporary basis, but are intended to evolve into some other organisational form within one to two years. Some of them will end up as social enterprise companies, others as foundation trusts, others will probably just wither and die as a host of commercial rivals grab the business.

There are claimed benefits for patients. People will be ‘empowered through choice’, apparently. Choice is a particularly charming euphemism for privatisation. Even better, patients will be given ‘personal budgets’ to go and buy their own health care. The clinical risks in this are substantial. It’s also about establishing the notion that when your allocated pot of money runs out, you top up your care yourself. This becomes a rapid erosion of the concept of free healthcare.

The NHS in London is intended to be a ‘mixed economy’, according to Lord Warner of Brockley. Lord Warner was a Labour Minister for Health, forced to stand down in 2006. This followed the 2005 ‘Commissioning a Patient-Led NHS’ project and the 2006 attempt to flog off entire Primary Care Trusts to the private sector. The planned privatisation was so rapid that people noticed – and the Government was forced into undignified retreat. This time, they’re crossing their fingers and hoping they can get away with it.

For patients, and for NHS workers, we face the systematic dismantling of the NHS – UNLESS we organise a serious fightback. Eighty per cent of patient contacts are in ‘primary care’ – the community NHS services that give people a decent quality of life. The damage being done now to primary care is profound and potentially irreversible.

And Lord Warner? Doing very nicely, apparently. He went to work for the giant private corporation Deloitte in March this year as a ‘strategic advisor’. By a remarkable coincidence, the Department of Health has commissioned Deloitte to advise on the reorganisation of community health services.


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