The Tory stealth attack on the NHS

If the Tories have their way, they will break apart the health system, just like our schools. This i

The new coalition government has made a great deal out of ring-fencing the health budget, giving the public the impression that the National Health Service will not suffer the cuts that other departments are facing. It is fast becoming clear, however, that there will be significant cuts in health like everywhere else. Plans put forward by the Conservative Secretary of State for Health, Andrew Lansley, if allowed to proceed, will undermine the structure and principles of the NHS in the largest overhaul of the service since its foundation.

The idea is to hand over the NHS budget to GPs, who will then commission services on behalf of individual patients. There has been little public discussion of the proposals, and the extent of the planned reorganisation - and the commensurate cuts in budget - is only now leaking from private briefings to key managers.

The NHS budget for 2010-2011 is £110bn and there are around 40,000 GPs working in England and Wales. At present, the budget is divided among the ten strategic health authorities (SHAs), which devolve it down to primary care trusts (PCTs). The strategic authorities set strategy and hold local delivery agents to account. The PCTs commission services from hospitals, GPs, opticians and primary services. Trusts have increasingly been forging strong links with local authorities to provide social care to the elderly and people with disabilities or other needs.
Under the plans, this infrastructure will be demolished and the SHAs abolished. The PCTs might survive, but with reduced powers and little or no authority over budgets or services; it is most likely that they will simply be employed by doctors as the administrative mechanism to purchase health services for individual patients. Richard Sykes, chairman of the London SHA, recently resigned in protest.

The last major reorganisation of the NHS took place in 2002 and has therefore had less than a decade to settle. The PCTs are midway through a restructuring process to separate the provider arm from the commissioners; now, no one seems to be sure whether this will proceed. There are undoubtedly bureaucratic tangles, but these are not insurmountable.

Stealth care

The new vision for GP-led commissioning envisages both sole practitioners and group practices handling the entire budget and commissioning services for their patients from hospitals, local authorities, private companies and primary services. There are questions concerning the details, not least whether GPs will want to take on this responsibility. Will single GPs be prepared or be able to commission such a wide range of services, or will they delegate to a consortium of local doctors? Will they subcontract the commissioning process to private companies involved in health care and so bring privatisation to the NHS by stealth?

It is not clear where public consultation fits into the GP-led model. The Health Secretary may argue that, because decisions are made with individual patients, this is inherently a form of consultation. But it would constitute a fragmentation of the pro­cess, as there would be no forum for leading discussion on, for example, investing in new specialist trauma services at particular hospitals, or reconfiguring stroke services. The SHAs have been the lead agencies conducting consultations. If they are abolished, this kind of consultation may also be lost.

It is also unclear how strategic decision-making will be conducted, if at all. Just as the schools system is being broken apart, taking away the strategic responsibilities of local authorities, so it is with health. The "big society" seems to mean the abolition of the collective.

Public health will be another casualty. Lives are saved through the promotion of healthy lifestyles and public education, as well as programmes to help people, say, give up smoking. Focusing such attention on health inequalities is one of the ways that we direct health services at the poor. But it appears that the expenditure on public health initiatives will be slashed from 7 per cent of the allocated budget to just 4 per cent.

PCTs are being told to reduce their management and administrative costs by roughly 50 per cent. The effect of this is to hobble any attempt at strategic management. Many targets have now been abandoned. Although there has been some unease at the rigidity of target culture, it is undeniable that imposing targets and holding people to account for specific time limits in accident and emergency units, for seeing a consultant and for performing operations have saved and improved the lives of millions of people.

Cities will be particularly hard hit by Lansley's shake-up. In London, there are probably several hundred thousand people who are not registered with a GP and they will not be able to get any access to health care. Anyone who is not eligible to register with a GP could be denied medical and health services.

Ask a doctor

Since its foundation, the NHS has been redistributive. It was designed to redistribute to the poor so that health inequalities are reduced. Its success has been patchy, but that objective is embedded at all levels and in every service. If strategic planning is abolished and service purchasing is fragmented, the aim of reducing inequality will be abandoned, too.

Lansley is a man on a mission who has been developing these ideas from his constituency, South Cambridgeshire. No one I have spoken to seems to know if he has been talking to the doctors themselves.

If his plans are fully instituted, GPs' contracts would have to be renegotiated and they would be well advised to consider whether it is to their advantage - and that of their patients - to take over responsibility for managing the NHS. It could be a poisoned chalice. Doctors could be made to take the blame if the plan collapses, leading the way to the wholesale privatisation of the NHS.

Also opaque is the extent to which these proposals form part of an ideological programme under the leadership of the Prime Minister, David Cameron, and the coalition cabinet, or whether ministers are being left to their own devices. There are similarities between the proposed education and health policies, but they do not appear to be co-ordinated as part of a coherent vision for the country. Every postwar government has come in with a clear ideology and a plan; for good or for ill, we knew what we were getting. The Conservatives have not presented this health plan to the public, and it is not even evident that they have made it clear to their coalition partners.

NHS agencies are being told that the new structure should be in place by 1 April 2012. There has been no announcement about any
of these changes - no public consultation and no critical review. Yet here they come.

Frances Crook is a non-executive director of a primary care trust and writes here in a personal capacity.

Journey of the GP

Before the Second World War, health care in the UK was piecemeal at best. The poor had little right to care - the lowest-paid workers could consult a GP, but their families could not - and many relied on charity.

This changed with the creation of the National Health Service in 1948. In a huge shift, each resident of the UK was from this point registered with a GP, who would act as the individual's point of entry into the medical system. In the early days of the NHS, GPs were demoralised, suffering from low pay and status. GP practices as they exist now began in 1955, when money was made available for individual doctors to develop grouppractices.

In 1990, while Margaret Thatcher was still prime minister, the "internal market" was formed; this allowed certain practices to buy services from other parts of the NHS. Successive reforms under Labour have left a similar system in place.

Meanwhile, GPs' status has improved, with recent contract changes allowing them to opt out of working during weekends and in the evenings. The press has criticised their pay as excessive. The figure is extremely variable, but a full-time practice partner now earns about £110,000, while a salaried GP earns approximately £74,000. A 2006 report showed that some GPs were earning £250,000 a year.

Samira Shackle.

Frances Crook is the Chief Executive of the Howard League for Penal Reform.

This article first appeared in the 05 July 2010 issue of the New Statesman, The cult of the generals

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The New Times: Brexit, globalisation, the crisis in Labour and the future of the left

With essays by David Miliband, Paul Mason, John Harris, Lisa Nandy, Vince Cable and more.

Once again the “new times” are associated with the ascendancy of the right. The financial crash of 2007-2008 – and the Great Recession and sovereign debt crises that were a consequence of it – were meant to have marked the end of an era of runaway “turbocapitalism”. It never came close to happening. The crash was a crisis of capitalism but not the crisis of capitalism. As Lenin observed, there is “no such thing as an absolutely hopeless situation” for capitalism, and so we discovered again. Instead, the greatest burden of the period of fiscal retrenchment that followed the crash was carried by the poorest in society, those most directly affected by austerity, and this in turn has contributed to a deepening distrust of elites and a wider crisis of governance.

Where are we now and in which direction are we heading?

Some of the contributors to this special issue believe that we have reached the end of the “neoliberal” era. I am more sceptical. In any event, the end of neoliberalism, however you define it, will not lead to a social-democratic revival: it looks as if, in many Western countries, we are entering an age in which centre-left parties cannot form ruling majorities, having leaked support to nationalists, populists and more radical alternatives.

Certainly the British Labour Party, riven by a war between its parliamentary representatives and much of its membership, is in a critical condition. At the same time, Jeremy Corbyn’s leadership has inspired a remarkable re-engagement with left-wing politics, even as his party slumps in the polls. His own views may seem frozen in time, but hundreds of thousands of people, many of them young graduates, have responded to his anti-austerity rhetoric, his candour and his shambolic, unspun style.

The EU referendum, in which as much as one-third of Labour supporters voted for Brexit, exposed another chasm in Labour – this time between educated metropolitan liberals and the more socially conservative white working class on whose loyalty the party has long depended. This no longer looks like a viable election-winning coalition, especially after the collapse of Labour in Scotland and the concomitant rise of nationalism in England.

In Marxism Today’s “New Times” issue of October 1988, Stuart Hall wrote: “The left seems not just displaced by Thatcherism, but disabled, flattened, becalmed by the very prospect of change; afraid of rooting itself in ‘the new’ and unable to make the leap of imagination required to engage the future.” Something similar could be said of the left today as it confronts Brexit, the disunities within the United Kingdom, and, in Theresa May, a prime minister who has indicated that she might be prepared to break with the orthodoxies of the past three decades.

The Labour leadership contest between Corbyn and Owen Smith was largely an exercise in nostalgia, both candidates seeking to revive policies that defined an era of mass production and working-class solidarity when Labour was strong. On matters such as immigration, digital disruption, the new gig economy or the power of networks, they had little to say. They proposed a politics of opposition – against austerity, against grammar schools. But what were they for? Neither man seemed capable of embracing the “leading edge of change” or of making the imaginative leap necessary to engage the future.

So is there a politics of the left that will allow us to ride with the currents of these turbulent “new times” and thus shape rather than be flattened by them? Over the next 34 pages 18 writers, offering many perspectives, attempt to answer this and related questions as they analyse the forces shaping a world in which power is shifting to the East, wars rage unchecked in the Middle East, refugees drown en masse in the Mediterranean, technology is outstripping our capacity to understand it, and globalisation begins to fragment.

— Jason Cowley, Editor 

Tom Kibasi on what the left fails to see

Philip Collins on why it's time for Labour to end its crisis

John Harris on why Labour is losing its heartland

Lisa Nandy on how Labour has been halted and hollowed out

David Runciman on networks and the digital revolution

John Gray on why the right, not the left, has grasped the new times

Mariana Mazzucato on why it's time for progressives to rethink capitalism

Robert Ford on why the left must reckon with the anger of those left behind

Ros Wynne-Jones on the people who need a Labour government most

Gary Gerstle on Corbyn, Sanders and the populist surge

Nick Pearce on why the left is haunted by the ghosts of the 1930s

Paul Mason on why the left must be ready to cause a commotion

Neal Lawson on what the new, 21st-century left needs now

Charles Leadbeater explains why we are all existentialists now

John Bew mourns the lost left

Marc Stears on why democracy is a long, hard, slow business

Vince Cable on how a financial crisis empowered the right

David Miliband on why the left needs to move forward, not back

This article first appeared in the 22 September 2016 issue of the New Statesman, The New Times