As the NHS is opened up to a tsunami of privatisation, the first alarming revelations about the potential disaster it will cause have already been revealed, in a number of articles in the Guardian over the last week — one dealing with “an assessment by the Faculty of Public Health (FPH) of the risks involved in the forthcoming overhaul of the NHS in England,” and the other dealing with reports that children’s services in Devon are likely to be privatised. Please note that Serco and Virgin Care, who are competing in Devon to run children’s services (despite having no experience), where insiders have explained that one or other company is likely to end up winning out over the NHS bid, were also targeted for direct action by the “Block the BIll” activists (as I explained here).
A risk assessment by the Faculty of Public Health
The first Guardian article provided an overview of a risk assessment by the FPH, which represents 3,300 public health specialists in the NHS, local councils and academia. The authors state, unequivocally, that the bill poses “significant risks … to patients and the general public” and could well damage “people’s health and patients’ experience of care.” They add, “It is likely that the most vulnerable who already suffer the worst health outcomes will be disadvantaged as a result of the enactment of the bill,” noting also that, as the Guardian put it,. “[p]oorer people are unlikely to be able to use the greater patient choice that the bill entails,” or, as the authors describe it, “Operation of choice in an environment of multiple providers will disadvantage those who are less educated, have reduced access to resources such as the internet, or for other reasons are less able to navigate the healthcare market.”
As the Guardian also explained, “Whole areas of healthcare provision may disappear and patients could be forced to go private because clinical commissioning groups (CCGs) — the new groups of local GPs who will become responsible for agreeing and paying for patients’ treatment from April 2013 — are only tasked with deciding what services are needed in order to ‘meet all necessary requirements’ of the populations for whom they are responsible.”
“As such,” the authors stated, “it is possible for CCGs to cease to commission services which are currently available through the NHS if they do not consider them to meet a reasonable requirement. Access to such services in the future might be available only through private healthcare.”
The Guardian also noted, “Handing GPs the right to decide what care is and is not provided “will also lead to an increase in geographical variation in service provision – the postcode lottery,” and such variation may become ‘more overt’ owing to doctors or patients lobbying CCGs.” It was also noted that “[i]mposing ‘a competitive market’ on the NHS will make it difficult to provide joined-up care for the rising number of patients with long-term conditions, as separate organisations collaborating to provide care ‘may be seen as anti-competitive and incur substantial financial penalties.'”
Dr. John Middleton, the vice-president of the FPH, said: “Patients with long-term conditions such as diabetes need co-ordinated care between GP, community and hospital. Under the current system they go to the primary care trust if any aspect of their care is at fault. Under the new system they may need to go to the NHS commissioning board for GP or optometrist care, the CCG if their hospital service or chiropody causes them a problem, Public Health England for their eye screening and the local authority public health service for their weight management and lifestyle services — it’s a recipe for uncoordinated care and everyone passing the buck. The current reorganisation is a recipe for things getting worse, not better.”
The document also, as the Guardian put it, “echoes warnings about the perils of the overhaul of child health already made in some primary care trust risk registers,” which are discussed in further detail below. The authors note, “Of particular concern are the risks identified around safeguarding children from abuse and neglect. The loss of designated professionals and weaknesses in information sharing between organisations poses an increased risk to the safety of children.”
Dr. Middleton also told the Guardian, “After several years of relative stability, this unwelcome and unnecessary reorganisation is disrupting services and splitting apart professional relationships which are needed to protect patients and the public.” He added, as the Guardian described it, that “NHS arrangements for emergency planning, screening and immunisation programmes are also ‘unsafe’ because of flaws in the bill.”
In conclusion, Dr. Middleton said, “The FPH remains concerned at the risks to public protection in emergency planning. NHS commissioning board directors of emergency planning cover huge geographical areas: from Land’s End to Dover, from Yarmouth to the Welsh border, and from Cheshire to Northumberland, and London. Each of these areas is huge and covers multiple Local Resilience Forums around which blue light services are organised, so NHS directors of emergency planning face extraordinary difficulties covering their sectors. Directors of public health at local authority level will ‘assure’ the system, but will have no powers or resources to enforce what needs to be done to make the systems safe.”
The Guardian added that the FPH also warned that “allowing private operators to provide more state-funded health services, together with the increased competition between NHS organisations, will increase the amount of money spent on administering the system and incentivise hospitals to treat patients needlessly” –huge examples of waste and fraud that are familiar from the US system.
The authors also stated, “The market environment will increase transaction costs and lead to the loss of economies of scale as large providers could be broken up. Market incentives will lead to supplier-induced demand where hospitals perform unnecessary and potentially harmful treatments to generate income. Management costs will also increase as the new GGCs will need to buy in legal and procurement expertise to support them in fulfilling their new commissioning responsibilities.”
Privatising the care of children
The second Guardian article explained how NHS Devon and Devon County Council had “shortlisted bids led by two private, profit-making companies — Serco and Virgin Care — to provide frontline services for children across the county, including some of the most sensitive care for highly vulnerable children and families, such as some child protection services, treatment for mentally ill children and adolescents, therapy and respite care for those with disabilities, health visiting, and palliative nursing for dying children.”
Although the shortlist for the £130m, three-year contract also includes bids by Devon Partnership NHS Trust, Barnardo’s and other charities, “a source close to the process” told the Guardian that “one of the two commercial companies’ bids look[ed[ likely to win the tender.” The final decision will be made in May, but the contract will be awarded to “the most economically advantageous” bid, according to criteria listed on the European Commission website, which is obviously a sign of what to expect in the future across the NHS as a whole.
The fact that this invokes the care of the most vulnerable children makes it particularly alarming, as the Guardian also noted, explaining, “The deal is believed to be the first of its kind involving children’s services on such a scale, although a small number of more limited contracts have also been awarded under reforms originally introduced by the Labour government,” and adding that critics “fear that the pro-competition measures in the new NHS bill will lead to a big increase in such deals.”
Voicing her criticism, Dr. Clare Gerada, the president of the Royal College of GPs, warned, “This is exactly what the bill is about. Devon is just one example. Once the bill goes through it will solidify what is already going on now. Contracts will be commercial in confidence, GPs will end up rubber-stamping them and any company for profit will put shareholders before patients. We will find the NHS as we know it fragmented.”
As the Guardian also explained:
Neither private company in the Devon bids has experience of running specialist children’s health services for the NHS. Serco, a London-listed company that made nearly £300m profit last year, plans to run the services in partnership with Cornwall Partnership NHS trust, which provides mental health and disability services to adults and community health services to children in the neighbouring county. But the extent of the NHS trust’s role is not clear and the PCT said it was commercially confidential.
Several public health experts critical of the bill expressed dismay and disbelief that high-risk children’s services were being contracted out. They questioned whether they could be safely run for profit.
John Ashton, director of public health for Cumbria, said: “What on earth are they doing taking risks with our children like this? Children’s services such as these are very complex and involve working with lots of agencies, from local authorities to police and schools, over long periods. How on earth a private company can function in that area when it needs to identify ways of making money is really hard to see.”
Professor Terence Stephenson, the President of the Royal College of Paediatrics and Child Health, which also opposed the bill, also questioned “whether private companies could run such important public services,” as the Guardian described it. He said, “It is hard to understand why a tender for something as important and complex as children’s services has not been put into the public domain for scrutiny by professionals. Children’s services are complex, as some tragic high -profile incidents have shown. It is essential that any provider has proven expertise in managing not only clinical services but also key areas such as safeguarding and, on the face of it, it does not appear that all of the shortlisted bidders have experience in managing such services.”
The Guardian also noted that Serco “has many contracts to provide management services to the government and local authorities, including running prisons,” and in 2006 was “contracted to provide the out-of-hours GP service” in Cprnwall. However, it “has drawn sharp criticism from health staff and the Liberal Democrat MP Andrew George, accused of compromising safety with cuts.”
Serco “was given an improvement notice by the NHS primary care trust that had commissioned it in 2007 following a number of incidents,” and in 2010 was implicated when a six-year old boy, Ethan Kerrigan, “died as a result of a burst appendix when the Serco out-of-hours service advised putting him to bed rather than sending a GP to examine him.” Local GPS have accused Serco of cost-cutting that has “left the service with insufficient transport and staff to meet needs,,” and explained that, one Christmas, “nearly one-fifth of calls to the service went unanswered because of lack of capacity.” The Royal College of Nursing has also criticised Serco, complaining that “proposed cuts to nursing staff working for the Serco out-of-hours service in Cornwall would compromise safety.”
Virgin Care, as the Guardian noted, “came into being at the beginning of this month, following a £4m investment by Sir Richard Branson for a 75% stake in Assura Medical, the loss-making medical services part of the Assura Group, a company listed on the London stock exchange, which acts as commercial partner in property and pharmacy services to GP consortiums.” Although it has no track record yet, it is already involved in “a major dispute with the NHS in Yorkshire, where it has reported the NHS primary care trust to the new adjudicator of contracts, the co-operation and competition panel for NHS services, for awarding a contract to the local NHS York Hospitals instead of to Assura/Virgin.” The Guardian noted that critics fear that “the increasing involvement of the private sector will divert NHS resources to legal fees and contractual disputes such as these with commercial bidders,” and I’m sure they’re right.
Professor Allyson Pollock, a leading critic of the NHS reforms, called the Devon tender “a clear privatising of the service for the most vulnerable,” and added, “It has huge implications elsewhere and serious questions have to be asked about why they are doing this when the bill is not yet law and it is not even clear what the statutory requirements will be for children’s services.”
In response to the news about Devon, John Ashton, the director of public health for Cumbria, and Maggi Morris, director of public health for Central Lancashire, were severely critical of the developments, and wrote the following article for the Guardian, which, for now, will stand as my final word on the Tory-led destruction of the NHS, and why it is such terrible news, and my introduction to the ongoing battle to mitigate the worst effects of Lansley’s reforms, and to campaign for the reforms to be scrapped:
Services for women and children’s health are a foundation stone of modern societies around the world. Public health services just about anywhere start by addressing the things that most affect the health of their children, from maternity care, to obstetrics, immunisation of babies and provision for healthy children. It is accepted and understood that these are too important to be left to individual attention and that the state assumes a responsibility for making them available.
That’s why the idea of privatising services affecting children is such anathema. The news that Devon is considering privatising a comprehensive range of its children’s services is alarming.
It’s true there are certain parts of maternal and child health that can be attractive to the private sector, and where they are predictable in terms of costs you can find very good examples of social enterprise running them effectively, for example in family planning. But when you move into the world of neonatal and obstetric care or complex childcare cases involving special needs, the private sector is very wary, precisely because when things go wrong the bills can be enormous.
When you move into the messy realities of children with multiple disabilities or multiple problems, involving lots of expenditure, how can you write legal contracts that are robust enough to cover every eventuality?
In public services, sadly we have to deal with cases of children who may need the involvement of many different agencies, from mental health services, to school, social workers, probation officers, the police, and drug services all working together. Who is going to write a contract that is legally binding for safeguarding children in such cases, and make sure there are not exclusion clauses that allow the provider off the hook?
In such cases, people have to work in partnership on the basis of trust, where a no-blame culture is developed that allows engagement with parents to do the right thing. This is the really important but undefinable work that is highly complex but generous enough to think of families in the round. It requires agencies to work as an interdependent team that puts the child at the centre. To mix profit into this equation is potentially disastrous. The only people who should profit from children’s services are the children and their families.
The private sector makes its money by making sure every burger is brought to exactly the right temperature in the same way. In health, that conveyor-belt system is a recipe for poor service. How many units of care will be in the contract for the child who has specialist needs because they were born with a heart problem or spina bifida? When a vulnerable child is at risk of abuse, you cannot refer to a contracted number of units of care or predict and put a limit on the cost.
The private sector segments risk and only picks up that which it can make a margin on. Based on a consumerist model of services, it will keep people in need and buying its services rather than doing what the public sector aims for, which is not just to treat sickness but to build resilience in children and adolescents so that in the future, when they become parents, their families will not fall into the same cycle of need.
The whole principle of the NHS, and one of its greatest achievements, is that it has been a social contract to pool risk. It is tragic that we are now about to throw that away.
Andy Worthington is the author of The Guantánamo Files: The Stories of the 774 Detainees in America’s Illegal Prison (published by Pluto Press, distributed by Macmillan in the US, and available from Amazon — click on the following for the US and the UK) and of two other books: Stonehenge: Celebration and Subversion and The Battle of the Beanfield. To receive new articles in your inbox, please subscribe to my RSS feed (and I can also be found on Facebook, Twitter, Digg and YouTube). Also see my definitive Guantánamo prisoner list, updated in June 2011, “The Complete Guantánamo Files,” a 70-part, million-word series drawing on files released by WikiLeaks in April 2011, and details about the documentary film, “Outside the Law: Stories from Guantánamo” (co-directed by Polly Nash and Andy Worthington, and available on DVD here — or here for the US). Also see my definitive Guantánamo habeas list and the chronological list of all my articles, and please also consider joining the new “Close Guantánamo campaign,” and, if you appreciate my work, feel free to make a donation.
On Facebook, Pauline Kiernan wrote:
Thanks Andy Am sharing
George Kenneth Berger wrote:
Posted by copying link, Andy. Good that you are keeping track of the changes.
Star Dust wrote:
Please digg Andy’s article on Digg. The word must go out. I fear the UK will look like the US all too soon.
Dejanka Bryant wrote:
Andy, as you know, I have child with special needs. She is 13 now; beautiful, lovely, caring child. I used to work as a volunteer for two years in my local Gateway club caring for adults with same needs. Most of them lived independently, in homes where they had carers paid by government. Recently, on BBC (I think) it was a programme about disabled children in those homes, looking after themselves and going to college where they teach them how to look after themselves; manage their financials, applying for jobs etc. Most of them wanted to work but hardly any company wanted to offer them any kind of work. They told me how they feel so betrayed. Some of them were so capable to work and earn money for living. Watching this programme I have learnt that my child will never be offered a chance to be independent, simply because this Government (previous one too) decided that children who are medical mistery, yet with learning difficulties and other special needs, do not have right to be helped. It is so important for them to socialise and learn many new skills rather than sitting with parents at home when they finished their secondary school and college (after 16).
Back to your article. Anyone deserves free healthcare. During Labour government it was not easy either for special needs children. For years we spent thousands of pounds going abroad for my child’s physiotherapy. All I earned I spent there. But Evelina Children’s hospital in London is the most remarkable hospital, with their excellent paediatricians. When I talked to some of them last month they expressed their grave concern of what is going to happen to their NHS patients. We have to listen to them, and us.
Thanks, Pauline, George, Star, and particularly Dejanka. We need to hear more personal stories, and we need to get more of these stories out. When my son was born 10 weeks prematurely, he received excellent care at King’s, where I realized that anyone with a premature baby who lived close to King’s was very fortunate, as they had experts in many neo-natal issues, and in the intensive care of premature babies. There was, if I recall correctly, a young woman from an estate in Peckham, a couple of African women, a woman who was addicted to heroin, various women with twins — and in one case triplets. All of the parents were luckier than 95 percent of the world’s parents with babies in need of serious care, because of the NHS and its expertise at King’s and the money that was being spent. I think we were particularly lucky, as afterwards the old ward closed, and a brand new PFI maternity building was built, but it didn’t actually belong to the NHS anymore, and there were — initially, at least — issues that made the old building look like a far more attractive and effective option. I began to fear then that private money was intruding far too much into what was supposed to be solely, or primarily about care, and having the Tories get their wretched bill passed troubles me enormously, as their entire rationale, for everything that matters, is to “shift the burden from the state onto the consumer.” In health, that will be a terrible, terrible disaster for an unknown number of people.
Dejanka Bryant wrote:
Indeed, Andy. In 1999, we spent a month in Guys hospital when our child was only 15 days old. Guys and St Thomas were among top ten hospitals in Europe. Their nurses and doctors, other staff who look after those ill children, and us, their parents, were excellent. Hospital school for children with serious illnesses, and terminally ill, was running without a fault. No one was turned down regarding their financial situation. Not a single child. I slept there every night. My husband too. He was going to his work from that hospital every morning. They saw how we appreciated their hard work. In return, they didn’t only care about our child, they looked after us too. I remember, when a nurse with a doctor came to us, saying: “Mr and Mrs Bryant, thank you so much being with you child all the time. The school is closed now. We put some sponge matresses on the floor for you so you can sleep there.” They knew how painful it was for us to sleep every night in those armchairs next to our child’s bed. Never I will forget that night when we slept for so long without being disturbed. In the morning, a nurse came to me and said with a smile, “I know, you worry that you didn’t breast-feed your child, but it is important for your body to have a long rest after so many days of worries and hearing the terrible news what might happen to your child in future. We gave her a formula milk. She slept soundly all night too. You can carry on with breast- feeding today, to help her to recover.” I don’t want to forget their care from that time. Same happened in 2005. My child was in their newly opened Evelina hospital for children for the operation of her both legs. Again, children from care homes, orphans, disabled, sick, from unprivileged or privileged families, were all cared for by our NHS. I am so grateful to you, Andy, writing about your concerns about this great NHS of ours, which might be destroyed in no time if this wretched Tory bill is going to be legally accepted despite a growing opposition to it by the numerous medical bodies and people of our country. What TUC is going to do about it it remains to be seen.
Dejanka Bryant wrote:
Unfortunately, Andy, Serco does have experiences running their services across our NHS, for a long time. http://sercofilm.co.uk/index.php/news/12-serco-film/news/40-serco-cornwall-s-gp-service
I picked up this story from the links provided in one of your articles about the NHS.
Thanks again, Dejanka. My experiences were also in 1999 — December 1999 to February 2000, actually. For the first two weeks my wife and I were allowed us to live in the hospital. We had our own room, which we even decorated with Indian textiles, and on Christmas Day 1999 our friend Tim brought us Christmas dinner — actually, salmon! The care was remarkable for everyone, regardless of their background, and after both Gordon Brown and David Cameron had the most profound experiences anyone could have with the NHS — with very ill babies and children — I couldn’t, and still can’t understand how either man could let anything happen to damage or destroy the NHS.
Dejanka Bryant wrote:
Andy, what Labour and *their* TUC have been doing all these days? Instead to organize a massive demonstration against this appaling ConDem’s Bill, they decided it’s better to exploit this situation for their benefits. Letting NHS and Social Services to be destroyed, just because Labour can pick up more political points in the next election is unacceptable, actually, criminal. I was stunned when I read someone’s tweet from the rally ‘Save Our NHS’, London, “this was not about NHS, it was a rally to gain support for Labour.” I was there, but failed miserably to understand his feeling. Now, I know. You can’t expect from the couple hundred people to change anything, do you? Demonstration on 17 March was insignificant, too. TUC failed miserably to call for the massive strike against this Bill, leaving their members, and others, to wonder around without a clue how to organize themselves. In fact, it was the Labour party who started the privatisation of our NHS, long time ago, with their lies. ConDem accelerates it brutally, with no regards whatsoever towards the most vulnerable people living in our society. Bitter pill we were forced to swallow. It’s side effects are obvious now.
I know, Dejanka. The failure of the unions to look beyond their own pension issues has been a profound disappointment. There should have been a rally to try and get a million people out against the privatisation of the NHS, the assault on the disabled, and the ongoing cuts in general, and their savagery and their failure. The bigger picture isn’t that difficult to work out, surely?
Brena Easterday wrote:
It is hard for busy average people to work out the bigger picture. That is exactly why the assaults on the powers and cares and protections of the populace in both the UK and the US are broad and localized and multi-pronged. It’s like fighting the hydra. We attack one head here and another police force is privatized while we are not looking.
It’s a very good point, Brena. So many people are working so hard — to pay their mortgages or their rent, for example — that they don’t have much free time even to think about how they should be trying to find more free time to be out on the streets complaining. But people do need to find time to act before it’s too late.
George Kenneth Berger wrote:
I’ll post this here. I fear that just like in the Netherlands and Sweden, increasingly more doctors of all sorts will go for the money, with or without pressure and/or incentives. http://www.independent.co.uk/news/uk/politics/how-gps-are-set-to-make-a-killing-out-of-nhs-reform-7584572.html
Joyce McCloy wrote:
I hope the UK doesn’t end up like the US where we have over 50 million people who can’t access health care. Oh and then we have underinsured people and life time limits. Medical bills leading to bankruptcy. I live in the US and haven’t had access to health care since 2003. Can’t afford insurance, it would cost 2/3 of what I earn.
George Kenneth Berger wrote:
Thanks, Joyce. I moved to Europe in 72, with healthcare being one of my main reasons. I’ve lived in the UK, the Netherlands, and now Sweden. Similar changes for the worse are happening in these countries, with differences dependent on national politics. I’m terribly disappointed by what I am seeing. I read today that the Swedish healthcare system has an enormous surplus. That sounds good, but the savings come from quite tough new regulations regarding disability and payouts for necessary medical costs. I think this is criminal: where is that money going?
Thanks, George and Joyce. That’s a pretty conclusive indictment of the US system, Joyce, and I’m sorry to hear it. No country that is rich should be treating its citizens like that, but increasingly this is what is happening in the UK, and, as George points out, elsewhere in Europe, where governments are working hard to exclude more and more people from any kind of safety net.
Joyce McCloy wrote:
Andy do people outside of the US know what a crisis we in the US have? I have cousins in Australia and New Zealand (just discovered them a few years ago) and they were shocked to hear how bad things are in the US.
Some folks in the US have insurance but use up their “lifetime” limit if they get cancer. Everyone has a “deductible” that must be met – health care costs paid for out of pocket – before insurance will pay anything. There are all sorts of insurance plans depending on your ability to pay.
Right now I don’t have insurance, so if I get sick, get cancer or get in an accident (broken leg etc or much worse) I have no way to pay the medical bills which could be more than the value of my house.
My brother has insurance (he’s a lawyer and can afford it) but his deductible is $10,000 USD a year. Wow.
Some people have better insurance with lower deductibles. Like our politicians, our US Congress (half of whom are millionaires, perhaps by insider trading which is legal for them)
The point of privatization is to sell your health care system to insurance companies who will make a profit by denying coverage as much as possible. They will even use tricks.
Now in the US, we do have a health care system for senior citizens, called Medicare. It doesn’t pay for everything and some seniors still go bankrupt. Medicare is where the govt pays for the health care. Seniors have to pay a monthly premium for Medicare B – the part that covers doctors visits and testing.
Thank you, Joyce, for that explanation of how people are dropped from the equation when profit takes over. Your question is a good one. I think the people who know the value of the NHS both know and care about the state of healthcare in the US, but unfortunately there’s so much apathy in the UK that I have no idea if many people know what some determined corporations want to do to them, and to the NHS, to make a profit. I wish they did.
The analogy I use is with the insurance companies here in the UK who, if you have a car crash, say, will be looking for ways to avoid paying out, so they can maximise their profits. That’s bad, of course, but if you get swindled by an insurance company over a car, it’s not a matter of life or death.
With healthcare, however, and with the same kind of profit motive, the stakes are much higher, of course. Literally, life or death in some cases.
That’s enough to scare me. But then I’ve been ill, whereas many of those who don’t seem to care are fortunate enough not to have been. Or not yet anyway …
But as with so much of life these days, the main problem, it seems to me, is not just apathy, and people being misinformed, but a lack of empathy, of failing to imagine what it means to be ill, and what kind of care you would want.
Joyce McCloy wrote:
If you allow corporations to take over your health care, then CEOs will put the insurance companies’ profit first, and your health last. They will create deductibles you have to pay before you get care. Many people won’t be able to afford the deductibles yet will still be paying anywhere from 1/4 of their income to 1/2 of it for insurance premiums. Others won’t be able to afford the premiums at all.
The percentage of individuals without health insurance for all of 2010 was 16.3%
Brena Easterday Corporations running research is also a problem. They do not want to spend R&D money on small profit things like antibiotics. By their very “strictly for profit” nature they are not set up to support the overall good.
Thanks again, Joyce and Brena. You both make very good points. Joyce, having 1 in 6 people without coverage is such a disgrace, but I fear that profits will be made in the UK precisely by cutting away at whatever isn’t profitable, and that poor people will suffer disproportionately as a result. People here need to keep that figure in mind.
And Brena, the huge pharmaceutical corporations are capable of creating very useful products, of course, but the problem is: who will be able to pay for them? There have been long-running battles between philanthropists and Big Pharma over the cost of AIDs drugs in Africa, for example. How will these companies cope when more and more people in the West are also unable to pay?
This is part of the bigger problem facing our turbo-capitalist world — the steady impoverishment of the very people who need to be consumers indicates a broken system, but until it collapses totally, the hardship of the many will only increase.
Campaigning investigative journalist and commentator, author, filmmaker, photographer, singer-songwriter and Guantánamo expert
Email Andy Worthington
Please support Andy Worthington, independent journalist: