The gulf between politician and practitioner

The NHS is arguably the greatest gift that the Labour movement gave the British people and its destruction is a betrayal of the English nation.

Since 1945 the United Kingdom has enjoyed a national health system free for all at the point of access. Irrespective of one’s class or station in life, the National Health Service (NHS) has promised and delivered ‘Cradle to Grave care’ for over half a century. As a model, the NHS is socially just, integrated and cost effective. Arguably the most patient-centered, holistic and equitable health delivery system anywhere.

The NHS now faces fragmentation in pursuit of a politically motivated neo-liberal ideology and is in danger of leaving millions of Britons with inadequate health care. In March 2012, parliament passed the Health and Social Care Act, changing the structure and operation of the NHS. This legislation passed, despite fierce resistance from expert groups representing the interests of doctors, nurses and patients.

The government promised this legislation would reduce bureaucracy and drive down costs through competition. Allowing in private health providers would also increase patient choice. From April 2013, family physicians will be in charge of commissioning for their local communities. Foundation trust hospitals were also created, beholden to compete with each other and third party providers to supply core services. Hospitals failing to attract significant patient volumes, will simply ‘go to the wall’ thus ensuring competitively priced services for patients in a free market.

This reorganisation threatens the core norms that make the NHS a cost effective, quality organisation. It erodes the ‘values driven’ professional ethic, reducing it to a ‘profit before patients’ corporate consideration. In the process costs have increased, health inequalities widened, and clinical performance is suffering.

If a doctor were guilty of such gross negligence, then the General Medical Council would rightly call them to task and ultimately terminate their licence to practise. No such accountability however faces the architects of this disaster. Such is the gulf between  politician and practitioner. How can those who do not understand or share undamental NHS values like ‘professionalism’, play such a seminal role in restructuring a service so dependent on values to function?

The excellent care patients traditionally received came from the willingness of health professionals to go ‘that extra mile’, to do the best for their patients. Going above and beyond the call of duty was the norm and not the exception within the NHS I served as a junior  doctor. Professionalism, unlike profit/loss accounts, is not easily measurable, but fundamental to practitioner empowerment and excellent patient care. The free market threatens this.

Sacking managers and reallocating commissioning will not streamline costs or result in better commissioning choices. Many family physicians are already struggling with heavy clinical workloads and are not interested, or equipped to commission. There is also the danger of former managers being brought back as consultancy to fill skill gaps. This is expensive, especially when their compulsory redundancy package from the same service is taken into account. Such practices have already cost the UK tax payer an estimated £2bn.

The introduction of competition into the NHS internal market will not result in efficiencies or lower costs. Time and treasure will be expended establishing and evaluating tenders. Transaction costs and performance monitoring of third party contracts represent additional inefficiencies and there are grave dangers in trusting inexperienced providers with delivering vital medical services.

In the medium to long term the net price of health care is likely to rise as large private providers grow to establish monopolies. Initially, by outbidding smaller competitors, then achieving market share and subsequently inflating and fixing prices. This already seems to be happening and is only likely to get worse.

Ideally, saving the NHS requires repealing of the Health and Social Care Act and this is being mooted. In reality, however, it would prove complex and costly as many of the structural NHS changes have already been implemented. Limiting large corporate involvement and moving away from the false prophecy of the free market in health is vital.

There are inefficiencies in the NHS and they do need addressing. Professionalism, however, must survive and more co-operative structures fostered; where workers and patients own a stake in the organisation as mutually empowered partners. This might yet save and sustain our NHS.

Sundar Thavapalasundaram  writes in a personal capacity.