I attended a Unite meeting today at which we started to put together the Union’s response to Darzi’s ‘reforms’ of the NHS. I’ve spent a fair bit of time over the last week or two reading Darzi’s final report in preparation for the meeting.
The report, rather oddly, is called ‘High Quality Care for All’. Possibly this is intended to be ironic. I’ve always assumed Darzi doesn’t write his own reports, but whoever he uses is an absolute whizz when it comes to concealing grubby realities with fine-sounding rhetoric.
One of the most poisonous strands of Darzi’s plans is the intention to roll out ‘personal budgets’. This isn’t Darzi’s own idea; it’s been touted by a ragbag of rightwing politicians for a couple of years now. Darzi claims that he has come up with the idea in response to ‘the enthusiasm we have heard from local clinicians’. Well, we hear it from health workers wherever we go, don’t we? We’re not bothered by pay cuts or redundancy or privatisation – everywhere the cry goes up from NHS staff, ‘We demand personal budgets for our patients’. Or maybe Darzi and his chums misheard.
We’re assured that there will be ‘safeguards’ – but it is hard to envisage safeguards that could make such a nasty idea work. So what is a personal budget? Patients are likely to have a single sum of money, equivalent to the entitlement for their clinical condition, allocated to them to use for purchasing their care. Darzi calls for a pilot of the approach – but a ‘national pilot’, which does rather strongly suggest that a decision has already been taken.
Personal budgets will carry a high level of risk for many NHS users – and are about passing risk to the individual, rather than ‘pooling’ risk across a large population. Privatisation is built into the plans. The stated benefit of personal budgets is that patients will be ‘empowered’ by being able to choose the providers from whom they buy services.
Personal budgets are also about managing costs – a priority for private sector providers.
And what about the risks to the individual patient?
- What if an initial treatment fails and the budget is exhausted? What if you make an unwise choice of treatment and regret it? Will there be more money available? What if patients choose a private sector provider who sells care at a higher price than the allocated budget will cover? This is the biggest imaginable threat to a comprehensive NHS. You’ll get a voucher towards the cost of the services you want, and you’ll pay for the rest yourself.
- The notion that the state will provide some funding and the individual patient will provide the rest is inherent in personal budgets. This is in reality a sharp shift away from the principle of a free NHS. There is little honesty here, as this is dressed up in rhetoric about choice and empowerment. However, the introduction of personal budgets marks a sharp shift away from a free (and comprehensive) NHS.
- There is nothing to stop private sector providers selling health insurance or charging top up fees – a risk noted by Alyson Pollock – so long as they satisfy whatever minimum standards are required by the NHS or privatised commissioner. The boundaries between public and private provision become very blurred indeed. There is a sharp erosion – in practice although not at the level of rhetoric – in healthcare that is free at the point of need.
There are other concerns:
- Why should we expect patients to be in a position to understand the evidence base for a treatment or therapy approach? Clinicians are taught about randomised control trials, peer reviewed journals and the like. Patients will be left to make their judgements on the basis of the internet, newspaper reports, hearsay, or the advertising material of those interested in making profits. For example, the Government report ‘Aiming High for Disabled Children’ proposes personal budgets for the parents of children with disabilities. It takes a very well-informed parent to choose services from NHS professionals who tell the truth (e.g. that a child with autism has a lifelong disability) in preference to an independent sector provider offering a miracle cure in return for a large sum of money.
- We know that private sector providers ‘cherry pick’ the patients from whom they can make most profit. They are unlikely to wish to take on the oldest, frailest and sickest patients, for the simple reason that the costs are too high. A roll out of personal budgets is likely to see a sharp shift of spending away from NHS providers to the private sector – eroding the ability of the NHS to provide high quality care. It is the most vulnerable patients who will suffer in this market economy. Universality is under attack.
- Middle class people are typically much more adept at accessing NHS services than the poorest, most vulnerable and sickest members of society (the ‘inverse care’ law). As accessing healthcare becomes an increasingly complex process, this tendency is likely to be exacerbated. Those who need robust public services the most will be the least able to exploit market mechanisms to their advantage – and will suffer most from the destruction of an NHS that provides comprehensive care as a matter of course.
We have to see through the rhetoric on this issue. This is a genuinely filthy proposal, and patients will pay for it with their lives.
There is an urgent need to oppose this – and many other aspects of New Labour’s plans for the NHS.