The hidden cost of NHS reform

These commercially-driven changes to our health system will be the worst of all worlds.

Last year the NHS paid out nearly £800 million in damages and costs for clinical negligence claims. Although part of an upward trend, it was not an exceptional year. In fact, some £15 billion is held in reserve against current potential liabilities: that is, existing claims or those which are anticipated but where no payment has yet been made. Even in a world inured by the financial crash to the mention of astronomical figures, these are significant sums of money.

We should, therefore, all be interested in the effect that the coalition's radical restructuring of the NHS is likely to have on the incidence of clinical negligence litigation. Thus far, however, the focus has been elsewhere. Unfortunately, both theory and experience say that there is much in these proposals which should concern us.

Whatever the sophistry of its proponents, a scheme in which of the provision of clinical care is outsourced to "any willing provider' can, in reality, mean only one thing: that the potential provider of that care will primarily be judged not on how good that care will be but on how cheaply it will be given. Even leaving aside the additional pressures on costs which apply uniquely to private healthcare organisations (the generation of profit and the payment of dividends to its shareholders), the need to undercut its competitors in the NHS will inevitably impact on their primary item of expenditure: their staff. Fewer doctors and fewer nurses will have to work longer shifts: in other words, the very environment in which mistakes are most likely to happen. Good news for the lawyers: less so for the patients and for the taxpayer who has to foot the bill when a claim is made.

If it were necessary to test that theory against experience, one would need to look no further than the provision of out of hours GP care. Until April 2004, this service was provided in-house by Primary Care Trusts and/or GP practices. Since then, it has been possible for this to be out-sourced to independent commercial providers (a concept which should sound familiar to those examining the current NHS proposals).

In the event, such concern was generated by the succession of adverse events which followed that change that in June 2009 -- and prompted by the tragic death of a patient in February 2008 after he was administered a gross overdose of diamorphine by a locum doctor from Germany -- the Care Quality Commission began an investigation into the provision of out-of-hours primary care services. Its interim statement on this investigation, in turn, prompted the Department of Health to commission its own inquiry. That report, published in June 2010, should have made uncomfortable reading for the evangelical proponents of the Coalition's plans. There is no indication, however, that anyone, from Mr. Lansley down, has ever read it -- or, indeed, seen any of the countless stories in the media about the failures of out of hours care in the years since 2004.

I am a clinical negligence barrister. According to the popular stereotype of the lawyer, I should be willing the Coalition's bill to be passed. I am, however, not only a lawyer: I am a taxpayer and a human being and I have seen too many tragic accidents and appeared at too many inquests not to implore the government to think again.

These proposals are patently driven by commercial imperatives rather than by consideration of patient wellbeing. Even on those narrow terms, and ignoring their human cost, they will not succeed if any money saved on the provision of care is simply spent on compensation for those who suffer as a result.

John Whitting is a QC and member of the Labour Party.

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Scotland's vast deficit remains an obstacle to independence

Though the country's financial position has improved, independence would still risk severe austerity. 

For the SNP, the annual Scottish public spending figures bring good and bad news. The good news, such as it is, is that Scotland's deficit fell by £1.3bn in 2016/17. The bad news is that it remains £13.3bn or 8.3 per cent of GDP – three times the UK figure of 2.4 per cent (£46.2bn) and vastly higher than the white paper's worst case scenario of £5.5bn. 

These figures, it's important to note, include Scotland's geographic share of North Sea oil and gas revenue. The "oil bonus" that the SNP once boasted of has withered since the collapse in commodity prices. Though revenue rose from £56m the previous year to £208m, this remains a fraction of the £8bn recorded in 2011/12. Total public sector revenue was £312 per person below the UK average, while expenditure was £1,437 higher. Though the SNP is playing down the figures as "a snapshot", the white paper unambiguously stated: "GERS [Government Expenditure and Revenue Scotland] is the authoritative publication on Scotland’s public finances". 

As before, Nicola Sturgeon has warned of the threat posed by Brexit to the Scottish economy. But the country's black hole means the risks of independence remain immense. As a new state, Scotland would be forced to pay a premium on its debt, resulting in an even greater fiscal gap. Were it to use the pound without permission, with no independent central bank and no lender of last resort, borrowing costs would rise still further. To offset a Greek-style crisis, Scotland would be forced to impose dramatic austerity. 

Sturgeon is undoubtedly right to warn of the risks of Brexit (particularly of the "hard" variety). But for a large number of Scots, this is merely cause to avoid the added turmoil of independence. Though eventual EU membership would benefit Scotland, its UK trade is worth four times as much as that with Europe. 

Of course, for a true nationalist, economics is irrelevant. Independence is a good in itself and sovereignty always trumps prosperity (a point on which Scottish nationalists align with English Brexiteers). But if Scotland is to ever depart the UK, the SNP will need to win over pragmatists, too. In that quest, Scotland's deficit remains a vast obstacle. 

George Eaton is political editor of the New Statesman.