NHS: Health and Social Care Act 2012

Viscount Hanworth Excerpts

Thursday 8th September 2016 Lords Chamber

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[Viscount Hanworth]

That this House takes note of the impact of the Health and Social Care Act 2012 on the current performance of the National Health Service and its future sustainability.

[Viscount Hanworth (Lab)]

My Lords, the very existence of the NHS is in danger, as is the principle of a universal healthcare provision free at the point of delivery. The NHS is being turned into a market-based system. The proponents of these changes envisage that the system will be financed by private insurance policies that will allow individual policyholders to determine the extent of their insurance cover and the level of care to which they will be entitled. The services will be provided by commercial organisations under the rubric of the NHS. Many of them will be displaying the familiar NHS logo in a deceptive manner. These changes have been proceeding gradually for the past 25 years, but they have been accelerating under the coalition Government and under the succeeding Conservative Government.

Notwithstanding the rubric of this debate, which will be concerned mainly with the developments since the passing of the Health and Social Care Act 2012, I shall begin by recounting the slow and inexorable process by which the original intentions of the NHS have been subverted. It will be helpful to understand how the NHS has been brought to a state where it has become easy prey to the provisions of the 2012 Act. The NHS, at its inception in 1948, was an egalitarian system. In the alliterative words of one commentator, it was envisaged that “judges and janitors” would occupy adjacent hospital beds. The NHS was to be funded by taxation, and no one was to be charged for its services.

The 1948 Act took hospitals into public ownership, but it left GP surgeries in private ownership and seemingly allowed GPs the dignity of continuing to be self-employed. Indeed, many of these surgeries were located in the private residences of the practitioners. Latterly, group practices in dedicated buildings have become the norm; and most doctors are now virtually salaried employees of the state. However, the enduring private ownership of surgeries has allowed them increasingly to fall into the hands of commercial enterprises.

It has been said that the intentions of the Conservative Party to privatise the NHS have been hidden in full view of the rest of us, and it is a wonder that they have so often and for so long escaped our notice. A statement of these intentions was contained in a Conservative policy document of 1988, authored jointly by Oliver Letwin and John Redwood and titled Britain’s Biggest Enterprise: Ideas for Radical Reform of the NHS. Others have drawn attention to this text. The polemic of these authors centred on their unjustifiable claims of administrative inefficiency in the NHS. Their pamphlet also inveighed against the supposed discomfort of the service, which it likened to that of a prison.

The authors were irked by the absence of such modern facilities as private telephones and television sets which, in their opinion, should be available to all those who cared to pay for them. They appeared to dislike the prospect of rubbing shoulders with the masses. To them, the prospect of being placed in a queue was a clear indication of the dysfunctional nature of the system. Their prescription for eliminating queues was to establish a market mechanism which would ration medical services by pricing them.

A minimum list of the measures proposed that should be taken in reforming the NHS may be enumerated as follows: first, the establishment of the NHS as an independent trust; secondly, increased use of joint ventures between the NHS and the private sector; thirdly, extending the principle of charging; fourthly, a system of health credits to be supplemented, if so desired, by the patients; and, fifthly, a national health insurance scheme.

In a telling admission, the authors acknowledged that these reforms could not be achieved in a single step, for the reason that the public would find them unacceptable. Therefore, they accepted that the agenda would have to be fulfilled gradually and in stages. True to this agenda, the current Health Secretary, Jeremy Hunt, is on record as having called for the direct funding of the NHS to be replaced by an insurance system. I would like to suggest that this agenda has been firmly in the minds of the Conservative policymakers from that day to the present. It is on account of its cunning concealment as much as its gradual realisation that many of us have failed to recognise what has been afoot.

The story goes back further in time. The process of reform—that is, the process of turning the NHS into a business—began in a modest way in 1983 under Margaret Thatcher, when she commissioned the so-called Griffiths report, which led to the introduction of a body of managers into a system previously run by clinical professionals. It was not until January 1989 that Thatcher announced a major review of the NHS, which aimed, so she said, to extend patient choice and to delegate responsibility to where the services were provided. These have continued to be the misleading mantras of most of the Conservative reorganisations.

The resulting National Health Service and Community Care Act 1990 created GP fundholding in order to promote a quasi-market within the National Health Service. The subsequent Health Authorities Act 1995 abolished the 14 regional health authorities, which were replaced by eight regional offices of a newly established NHS Executive. Here, we see another theme of the Conservative reorganisations, which claim to promote decentralisation but which actually accomplish the reverse.

There were indications that the incoming Labour Administration of 1997 would reverse some of these reforms. Thus, in 1997-98, GP fundholding was abolished by the Labour Government. However, Labour soon took over from where the Conservatives had left off. In 2001, primary care trusts were established. In 2002, NHS foundation trusts were announced by the Health Secretary, Alan Milburn, and they were established via the health and social care Act of 2003. These trusts were centred on large hospitals, which were to be given a degree of independence from the Department of Health and from the strategic health authorities, and which were to have a degree of financial autonomy. At the same time, an extensive outsourcing of ancillary services was encouraged.

That autonomy enabled the trusts to pursue private finance initiatives, or PFIs, whereby a massive investment in the NHS was achieved under the Labour Administration. The PFIs have bequeathed a crippling legacy of debt to the NHS. Many hospital trusts have been bled dry by contracts that are demanding exorbitant rates of return for periods of as much as 30 years. A typical hospital refurbishment costing perhaps £9 million will eventually yield the private contactor as much as £80 million, and it is estimated that the NHS is currently paying £2 billion a year in PFI-related costs. Much of this income is going offshore in avoidance of taxes. Of course, one of the purposes of PFI was to shift the cost of big projects out of government borrowing figures. The fallacy of that approach to social investment should now be clear to anyone.

In the campaign that led to the election of 2010 and to the formation of a coalition Government, David Cameron asserted that the NHS would be safe in the hands of the Conservatives and that there would be no further top-down reorganisations. These were flagrant deceptions. Within a short period, the Secretary of State for Health embarked on the preparation of a major piece of legislation, which was to become the Health and Social Care Act 2012.

Perhaps that was par for the course. As Professor Turnberg—my noble friend Lord Turnberg—remarked in a speech in February this year, there have been eight reorganisations of the NHS in the 16 years that he has been in the Lords; that is, one every two years. However, as the NHS England chief executive, David Nicholson, famously said in a speech to the NHS Alliance conference, the reforms demanded such a big reorganisation that “you could probably see it from space”.

The Bill was a huge document, but we may remind ourselves of its salient points. To begin with, the leading clause has been widely interpreted as relieving the Secretary of State of the duty to provide a universal and comprehensive health service in England. That duty has devolved on to the newly created NHS England health executive. This interpretation of the clause is debatable. Nevertheless, it has allowed the current Secretary of State to criticise the NHS when things have gone wrong, instead of taking the blame himself.

Under the 2012 Act, NHS hospitals are allowed to make up to 49% of their money from private patients. Presumably, this allowance was intended as a means of alleviating the financial problems of the hospitals. The Act abolished the primary care trusts and the regional health authorities, and replaced them with clinical commissioning groups, or CCGs, which now control a large proportion of the NHS budget and commission local services.

The Act proposed that general practitioners and other health professionals should be given the responsibility for commissioning the majority of health services. However, that is not what has happened; nor does it seem to have been what was truly intended. The CCGs are told what they can and cannot do by the bureaucrats of NHS England, which is the newly styled NHS Executive, and by its secretive local area teams. They have imposed stringent controls on what can be provided, and those controls have become increasingly restrictive in consequence of the financial exigencies of the NHS. Notwithstanding the centralised and hierarchical control that it has imposed, this reorganisation has created a so-called postcode lottery in the provision of services, of which the availability now varies widely across the regions.

The clinicians are typically represented on the CCGs by a small handful of GPs from the largest and most prosperous practices. Smaller practices working under increased pressure cannot afford the necessary time to be involved. In 2013, the British Medical Journal used the Freedom of Information Act to discover that more than a third of the GPs on CCGs have conflicts of interest due to directorships or shares held in private companies. Much of the work of the CCGs is already being undertaken by commissioning support units, which were due to be outsourced to commercial companies in 2016.

Perhaps one of the most significant provisions of the Health and Social Care Act is to be found in Section 75, which has established the requirement for competitive tendering for the provision of services. It is extraordinary that commercial interests, represented by commissioning support units, should have become, in some instances, both providers of health services and the providers of advice on commissioning.

The requirement for tendering has imposed a huge administrative burden on the NHS, which is entailed in the commissioning, invoicing and billing of these services. This is wasting money and it is wasting the time of already overburdened clinicians. It is also seriously undermining the provision of services. The introduction of commercial profit-seeking providers means that services may be pared to the bone.

Private clinics are now competing with hospitals to conduct routine surgery on the understanding that, if complications arise, NHS hospitals will be obliged to provide the remedy. Hospitals can be financially unsettled when cheap and easy functions are subtracted in this manner. Also, if they are teaching hospitals, the experience of routine operations is denied to trainee doctors.

There have also been significant commercial inroads into general practice, where there is now a serious shortfall in the number of GPs. The response of NHS England to the resignations and retirements of the members of a group practice has been to put the services out to tender under a so-called APMS contract, with a limited five-year term. Such contracts are liable to be taken by commercial enterprises motivated by profit and intent on saving costs. The short-term nature of the contracts discourages investment, and the cost-saving motive results in inadequate levels of staffing, with peripatetic locum doctors in place of resident GPs. The costs and risks of tendering mean that independent GPs will struggle to compete with larger healthcare corporations.

Why are politicians of all parties and senior civil servants so attracted to the prospect of the commercial provision of health services? In answer to this, I should observe that many of them have strong affiliations to private health that often entail pecuniary interests. Simon Stevens, the current chief executive officer of NHS England, spent 10 years as a senior executive in UnitedHealthcare, which is the biggest multinational healthcare corporation in the United States. I should also observe that, with Andy Burnham as a notable exception, the majority of former Secretaries of State for Health have financial interests in commercial healthcare.

The conditions are now in place for a wholescale takeover of the NHS by commercial enterprises. In spite of numerous withdrawals of the private sector due to unprofitability attributed to the exigencies of the NHS finances, and in spite of some outstanding cases of fraud and malfeasance among private providers, it appears that the proportion of the NHS budget devoted to purchasing from private providers is increasing apace. Some commercial enterprises, such as Serco and UnitedHealthcare, have pulled out of providing medical services to patients, leaving behind them a wake of disorganisation. The overstretched NHS has had to pick up the pieces. Nevertheless, the accounts provided by the Department of Health in July of this year have shown that 7.3% of total NHS expenditure in 2014-15 went to private providers, which represents an increase of 1.2% over the previous year. This is the biggest annual rise in both absolute and percentage terms since 2006.

Meanwhile, so-called sustainability and transformation plans are being demanded from local NHS areas by NHS England. These are aimed at saving large sums of money, while improving the quality of healthcare. It has become abundantly clear that such plans amount to dangerous fallacies. They have already been widely discredited. They would lead to widespread closures and amalgamations of hospitals, and they would strip the NHS bare. I beg to move.

--- Later in debate ---

[Viscount Hanworth]

This has been an interesting and disturbing debate. We have had a diversity of opinions regarding the state of the NHS and its likely future, not many of which have been favourable. I am heartened by what I understand to be the reaffirmation of the founding principles of the NHS by the noble Lord, Lord Prior; however, I am very doubtful of his optimism.

Be that as it may, I draw attention to the National Health Service Bill, a Private Member’s Bill that had its Second Reading in the Commons on 11 March. The Bill, which was known in a previous version as the NHS Reinstatement Bill, proposes to reverse the 25 years of privatisation in the NHS by abolishing the essential purchaser-provider split, by re-establishing public bodies and by enshrining that the NHS reverts to an accountable public service. The Bill, which has been presented again for the 2016-17 Session, had another First Reading in the Commons on 13 July. It received the support of numerous Labour MPs and even from some Conservative MPs. This Bill merits our attention, as do the speeches that accompanied its introduction.

I reiterate that I am very grateful for all contributions to what has been a very fruitful debate—at least I hope it has been.

Motion agreed.