McAvan contra mundum
Thank goodness for the independence of MEPS.
Few in Brussels ever cast a sideways glance across the channel at the
NHS , Europe’s second largest employer after the Red Army; whose annual budget of about £85bn is actually about equivalent to that of the European Union. Its health service status ring-fences it from the attentions of the single market enforcers.
Yet the venerable British institution is undergoing unprecedented reform which some compare, in its own world, to the collapse of the Soviet system. And in fact, the NHS is introducing a single market of its own.
The new reforms involve an enormous expansion of patient choice, a new payment system for hospitals, foundation trusts, independent sector treatment centres, practice-based commissioning.
A lot of doctors are unhappy about this, partly because the pace of change has come so fast, notes Julian Legrand, a professor of social policy at the LSE and a former No 10 adviser, wrote recently. Partly because doctors are losing their autonomy. Consultants are used to having their own fiefdoms; now they have to deal with hospital managers on the one hand and performance targets on the other. They also have more constraints on their rights to prescribe medicines.
Targets, redolent of the Soviet era, are losing their popularity. But the reforms present another threat: that of the market, which is increasingly becoming a substitute for targets. Legrand argues that the discipline of the market is an improvement over the discipline of command and control targets, since these are disenfranchising, while the market offers more scope for initiative and dynamism.
The downside is job insecurity, but people lose their jobs in command and control systems also, and are in such systems much less able to get another job. Anyway, doctors can always go abroad.
With doctors, targets were far from popular, but this new system appears even less so.
At several spring and summer medical conferences that I attended, I heard them complain bitterly about the system. One compared being a GP in the new choose and book NHS – where GP and patient will sit in front of a screen and choose hospitals - to being a maitre’d in a restaurant. The loss of a sense of status is palpable, despite the recent salary increases. The BMA annual plenary voted to oppose the reforms, against the wishes of their leadership. “because the BMA leadership want their gongs” in the words of a health academic.
“If the government continues like this by the end of the decade the NHS will effectively have disappeared as a national institution providing the most economical health services in the world, freely and equally to all,” Colin Leys, a health expert opposed to the government’s reforms told me.
“The ‘NHS’ logo will still exist, but increasingly just as a logo attached to private hospitals and GPs’ surgeries.
“Soon entire clinical services – for example, mental health or paediatrics – will become unavailable locally, as hospitals drop unprofitable activities in order to survive in the market, and without any opportunity for the public to prevent it.
“This unevenness will be offset by new opportunities to buy ‘superior’ or ‘enhanced’ services through ‘copayments’.
“Those who can afford it will buy the kind of services that the NHS was created to provide free to everyone, regardless of ability to pay. Everyone else will get a ‘basic’ service, which will decline steadily as the middle class loses interest in it, and good staff flee to better-resourced and less stressful work. If this picture seems far-fetched it is because government spin and media bias have prevented a clear picture emerging.
Most of it has already occurred, or is explicitly planned.”
He could well be right. While choice is good in theory, it needs an informed customer, and healthcare is not cereal. It will favour the well off, who can afford to travel to take an advantage of the freedom to go wherever they wish..
Hospitals will be further consolidated by uncertainties of the system of payment by results in arrears, which will mean less cash flow for many hospitals, already impoverished by high management consultancy fees (An unrelated fact: Patricia Hewitt, the health secretary, is a former management consultant herself.) Any benefits of choice will lose out to inequality pf provision, as rural and unprofitable hospitals close down – it will be like the fiasco of railway privatisation. As Leys puts it: “Most people want as little choice in hospitals as they do in fire brigades.”
The interesting implication for Brussels is what impetus this will give for a health services directive this autumn. The directive says patients can go abroad for treatement if the waiting lists at home are too long - and the home state will pay, which could expand choice dramatically., though the exact details of the conditions have yet to be ublished. Although current ECJ judgments say that choice of care abroad is subject to waiting lists at home, one doctor I spoke to said that, since choice of any UK hospital was now being offered, he would be happy to let the money follow the patient abroad as well, especially if it was cheaper. This will be an interesting quandary for Labour MEP Linda McAvan, the socialists’ health spokeswoman. She is tentatively in favour of a health services directive; but has also said carelessly – or obliviously?- that: “Most people just want to decent, functioning care locally.” Which, of course, would be much more at risk from continental choice - France or Germany, take your pick - a la carte.
Thank goodness for the independence of MEPS.
Few in Brussels ever cast a sideways glance across the channel at the
NHS , Europe’s second largest employer after the Red Army; whose annual budget of about £85bn is actually about equivalent to that of the European Union. Its health service status ring-fences it from the attentions of the single market enforcers.
Yet the venerable British institution is undergoing unprecedented reform which some compare, in its own world, to the collapse of the Soviet system. And in fact, the NHS is introducing a single market of its own.
The new reforms involve an enormous expansion of patient choice, a new payment system for hospitals, foundation trusts, independent sector treatment centres, practice-based commissioning.
A lot of doctors are unhappy about this, partly because the pace of change has come so fast, notes Julian Legrand, a professor of social policy at the LSE and a former No 10 adviser, wrote recently. Partly because doctors are losing their autonomy. Consultants are used to having their own fiefdoms; now they have to deal with hospital managers on the one hand and performance targets on the other. They also have more constraints on their rights to prescribe medicines.
Targets, redolent of the Soviet era, are losing their popularity. But the reforms present another threat: that of the market, which is increasingly becoming a substitute for targets. Legrand argues that the discipline of the market is an improvement over the discipline of command and control targets, since these are disenfranchising, while the market offers more scope for initiative and dynamism.
The downside is job insecurity, but people lose their jobs in command and control systems also, and are in such systems much less able to get another job. Anyway, doctors can always go abroad.
With doctors, targets were far from popular, but this new system appears even less so.
At several spring and summer medical conferences that I attended, I heard them complain bitterly about the system. One compared being a GP in the new choose and book NHS – where GP and patient will sit in front of a screen and choose hospitals - to being a maitre’d in a restaurant. The loss of a sense of status is palpable, despite the recent salary increases. The BMA annual plenary voted to oppose the reforms, against the wishes of their leadership. “because the BMA leadership want their gongs” in the words of a health academic.
“If the government continues like this by the end of the decade the NHS will effectively have disappeared as a national institution providing the most economical health services in the world, freely and equally to all,” Colin Leys, a health expert opposed to the government’s reforms told me.
“The ‘NHS’ logo will still exist, but increasingly just as a logo attached to private hospitals and GPs’ surgeries.
“Soon entire clinical services – for example, mental health or paediatrics – will become unavailable locally, as hospitals drop unprofitable activities in order to survive in the market, and without any opportunity for the public to prevent it.
“This unevenness will be offset by new opportunities to buy ‘superior’ or ‘enhanced’ services through ‘copayments’.
“Those who can afford it will buy the kind of services that the NHS was created to provide free to everyone, regardless of ability to pay. Everyone else will get a ‘basic’ service, which will decline steadily as the middle class loses interest in it, and good staff flee to better-resourced and less stressful work. If this picture seems far-fetched it is because government spin and media bias have prevented a clear picture emerging.
Most of it has already occurred, or is explicitly planned.”
He could well be right. While choice is good in theory, it needs an informed customer, and healthcare is not cereal. It will favour the well off, who can afford to travel to take an advantage of the freedom to go wherever they wish..
Hospitals will be further consolidated by uncertainties of the system of payment by results in arrears, which will mean less cash flow for many hospitals, already impoverished by high management consultancy fees (An unrelated fact: Patricia Hewitt, the health secretary, is a former management consultant herself.) Any benefits of choice will lose out to inequality pf provision, as rural and unprofitable hospitals close down – it will be like the fiasco of railway privatisation. As Leys puts it: “Most people want as little choice in hospitals as they do in fire brigades.”
The interesting implication for Brussels is what impetus this will give for a health services directive this autumn. The directive says patients can go abroad for treatement if the waiting lists at home are too long - and the home state will pay, which could expand choice dramatically., though the exact details of the conditions have yet to be ublished. Although current ECJ judgments say that choice of care abroad is subject to waiting lists at home, one doctor I spoke to said that, since choice of any UK hospital was now being offered, he would be happy to let the money follow the patient abroad as well, especially if it was cheaper. This will be an interesting quandary for Labour MEP Linda McAvan, the socialists’ health spokeswoman. She is tentatively in favour of a health services directive; but has also said carelessly – or obliviously?- that: “Most people just want to decent, functioning care locally.” Which, of course, would be much more at risk from continental choice - France or Germany, take your pick - a la carte.
