Thursday, 3 February 2011

Socialist Students Talk: The NHS

Heres a quick talk I gave at the Socialist Students meeting to kickstart off a debate/talk about the NHS in its current form and what the reform of the White Paper means for it:

First a quick history of the NHS. In the aftermath of WW2, the UK was in shambles. A system was proposed to deal with this which we call a “cradle-to-the-grave” welfare system, i.e a welfare system that covers a citizen from birth until death, as proposed by the Beveridge Report. This report was created by an economist and social reformist known as William Beveridge. One of the most fundamental assumptions of this report was the establishment of a National Health Service. This task fell to Clement Attlee’s Labour government and his Secretary of State for Health, Nye Bevan.  Prior to the NHS’ establishment, the healthcare system in the UK was provided by a mishmash of private, municipal and charity entities. Upon seeing the regional inequalities generated by this system, Bevan decided that the way forward for healthcare should a national system, wherein each citizen would be signed up to a GP as the point of entry, and would have access to any kind of treatment free at the point of use. Over time, the whole concept of “free at the point of use” was shaken as the cost of the NHS hit government finances and we saw the introduction of paying for prescription charges and dental treatment, something we’re familiar with today. These introductions caused a split in the party when Bevan resigned from the Cabinet over them, leading to the defeat of Labour in 1951.

Now currently NHS money is spent on a variety of different sectors. You have, roughly, 48% on Hospitals and acute care, 9% on GPs, 10% on prescriptions, 10% on mental health, 15% on community services like district nurses, 5% on dentists opticians and pharmacies, and finally 3% on Management. Management is known as commissioning. These are the people who look at the providers in your area, look at the money thats provided and decide who is going to provide which services. Some NHS services are provided by private providers. GPs are private businesses for example, as are dentists, opticians and pharmacies. Under the government’s proposals, which i believe were voted on a day or so ago, GPs will be given control of most of this budget. Few GPs will not want to do this commissioning, however. 4 in 5 don’t want to do it, and who can blame them? It isn’t their job, they don’t have the time or training to do this effectively. So instead, they will buy in the commissioning from services from the private sector. This is, essentially, the privatisation of commissioning. However, the government also wants to create the “largest social enterprise sector in the world”, out of the NHS. A social enterprise is a private, not-for-profit business. It is not publicly owned. It is not publicly run. The public have no say in how a Social Enterprise is run. This means that hospitals will be taken out of public ownership, alongside community services, continuing care and mental health services. NHS Trusts will be abolished. Social Enterprises will be the only option for most NHS providers. The result of this is that none of the NHS will be publicly owned. However, many find it hard to object to non-for-profit businesses running healthcare. But the government also wants the private sector to provide many more services. What does this mean? Over time the private sector will provide more and more services for SEs. In some cases, they will take over SEs. The meaning of this is that there will be no publicly owned or run services. Some services are SEs, but some services are provided by for-profit businesses. This represents the privatisation of the NHS. This was the result of the NHS White Paper last year.

The curious thing is that the public doesn’t seem to support this. Heres a bit from the Guardian debunking the notion that the Modernisation Of The NHS is a popular idea:
“The YouGov survey found that only 27% of people back moves to allow profit-making companies to increase their role the NHS.” 
“Overall, 50% of the 1,892 respondents opposed the policy. But hostility was more evident among Lib Dem voters, 56% of whom said they were against, with just 30% in favour. Conservative supporters were also split: while 46% backed the use of private firms, 32% were against.” 
“The poll also reveals that half the public oppose the new GP consortiums that will emerge across England, using private management groups to help them with finance, planning and management. Lib Dem voters are even more hostile to this, with 57% against, while among Tory voters, 40% back it with 38% against.”  - Source

However, this poll was commissioned by Unison, so obviously there will be a bit of bias in here.

Now you will hear that, as we heard from Cameron during the televised debates, that modernisation of the NHS is needed because “our health outcomes lag behind the rest of Europe”. This isn’t limited to just the conservatives, but also spreads to tabloids when they’ve run of nonsense about immigrants stealing swans. But much of this is nonsense. Healthcare statistics require context and cannot be pulled out of a report and thrown into a debate. They need context to give them meaning. For example, if i just quote the cancer mortality rate of the UK off the bat (which is 147 per 100,000). The same report that gave this figure, the WHO’s World Health Statistics Report 2009, also gives the figure of 91 out of 100,000 for Namibia cancer mortality, 107 per 100,000 for Bangladesh and 95 per 100,000 for north korea. Surely, the NHS cant provide worse healthcare than North Korea?

We must remember at all times that Britain has the most equitable access to healthcare in the entire world, with multiple screening programs for various cancers and pre-cancer conditions. Couple this with strong post-mortem requirements and a highly skilled pathologists. North Korea does not have these. Patients with cancer there may lack a doctor to diagnose them before dying at home and being buried without a post-mortem. Inevitably, the access to screening programs inflates mortality statistics artificially, making the NHS look worse. Cancer is also a disease of the old generally, with the average age of diagnosis for breast cancer being 65. The average life expectancy in Namibia is 60, so people do not live long enough to contract cancer, instead dying is easily preventable infections etc. We must also remember that cancer is not a universal disease. Comparing the survival rates for stomach cancer for Japan and Britain makes us look rather bad. However, Japan has a higher incidence of stomach cancer than Britain, leading to very strong nation-wide screening programs. These programs would not be cost effective here, compared to screening for other cancers that are more common.

Finally, cancer statistics are by definition out of date by the time they’re published. The EUROCARE-4 statistics involve patients diagnosed with cancer between 1995 and 1999, who were followed through to 2002 before the data was published. But in 2000 the NHS Cancer Plan was published, changing the uncoordinated mess that was British cancer care at the time into a formal, structured system with a greater emphasis on screening and on preventative programs to stop cancers from developing in the first place.  The results of this plan will take years to be observed because of the time lag between a cancer first developing and eventually being diagnosed, making it meaningless to use statistics from before the plan was implemented to criticise the current system. 

Finally, we move onto NICE, the National Institute for Health and Clinical Excellence. This organisation, in a simplified sense, used to conduct research into the efficiency and cost-effectiveness of treatments on the NHS. However, NICE has recently been neutered. They have been turned from an authority into a consultancy. They make recommendations now, but have no control at all whether GPs follow their advice. What this will probably mean is that we will see funding move from efficient, cost effective treatments and instead will begin to middle-england’s obsession with ludicriously expensive cancer drugs that give very little benefit or longevity of life that the Daily Mail et al so love to rant about.
We are standing on the precipice of the destruction of the NHS. We will slide back to a post-code lottery system for treatments. In the name of choice, and fairness and all those neoliberal buzzwords have been used to force the private sector to further entrench itself into the NHS. And we will probably not wrestle it back.
Special thanks to NHSSense for the cancer statistics clearup.

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