"The NHS is being hollowed out from within; that's not efficiency." Photo: Getty
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NHS reform and the hollow marketisation myth

A metamorphosis is taking place; a mutation of the NHS from a public service into a lucrative marketplace.

When the chief executive of NHS England produces a 39-page, 15,000-word rescue plan for the health service that, a senior doctor later told me, “doesn’t even mention the real problem in the system”, you know something is up.

Not that it’s any great surprise. Simon Stevens isn’t likely to agree with my source that the real problem in the NHS is a prevailing ideological dogma that “private is good and public is bad” among top brass, nor that the aggressive marketisation programme currently underway is all based on a myth. The private healthcare man turned NHS-saviour has only been in his post for seven months after 10 years at global giant United Health Group, and old habits die hard.

But the real paradox at the heart of Stevens’ five-year plan is that he calls for ruthless efficiencies and then turns a blind eye to the sort of “grotesque financial waste” that consultant clinical oncologist and National Health Action Party (NHAP) co-leader Clive Peedell says is crippling the system.

Peedell says: “Wasteful internal markets, commissioning support units, management consultancy fees, the cost of procurement of clinical services, profit-taking by private providers, the cost of fragmenting pathways due to outsourcing components to private contractors, and PFI deals bankrupting our hospitals; they are draining billions from frontline care in our NHS”.

A metamorphosis is taking place; a mutation of the NHS from a public service into a lucrative marketplace. None of this is particularly new – but since the Health and Social Care Act kicked in two years ago, trusts have been legally obliged to compete with private providers over contracts, and take on the extra administrative costs of doing so. Allyson Pollock, professor of public health research at Queen Mary University of London, says: “It’s quite clear that the government wants to contract out as much as it can before the general election, but there’s no data about the costs for trusts such as lawyers and management consultants in doing this”.

And after a slow start, the scrum has really kicked in now. Campaign group NHS Support Federation has recorded five times more contracts coming onto the market between July and September this year, a cool £2bn’s worth, than in the first three months of life under the Health and Social Care Act when only £266m was up for grabs. Bound by competition laws, NHS trusts find themselves in the position of having to spend tens, maybe hundreds of thousands bidding to carry on running services they already deliver, or, even worse, to then lose out to private providers that have cherry-picked the contracts and put all of their corporate weight behind winning them.

Take Cambridgeshire and Peterborough for example, where a million pounds of taxpayer money was wasted on the procurement process of older people’s healthcare and adult community health services before the CCG finally decided that Cambridgeshire and Peterborough NHS Foundation Trust should carry on running the service.

Why are such tremendous burdens being overlooked by Stevens? Or the hideous levels repayments for the same PFI loans he advocated when he had Tony Blair’s ear back in the noughties? Why no mention of the £4.5bn a year that Calum Paton, Professor of Public Policy at Keele University, conservatively estimates is the cost of administering an internal market he describes as “costly and of dubious effectiveness”, or the extortionate legal fees just being in that market forces trusts to stump up?

GP and anti-privatisation campaigner Dr Bob Gill says: “A market doesn’t work in healthcare; the administration of it just drives up costs. The NHS is being hollowed out from within, assisted by people from banking and the private sector who are dumbing down the service and delivering everything as cheaply as possible. That’s not efficiency”.

Neither is, Gill argues, a system in which a hollowed-out NHS has to pay when those private companies fail in their duty. Private companies like Vanguard Healthcare, which had its contract with Musgrove Park Hospital in Taunton terminated after a series of post-surgery complications, leaving Musgrove medical director Dr Colin Close admitting, “any financial responsibility would rest with us”.

How is all this playing out? Kathryn Anderson is a nurse at the Royal Free Hospital and NHAP general election candidate – in Iain Duncan Smith’s constituency. She says that far from bringing in greater efficiency or care, these new wasteful costs are having the opposite effect in the wards. “All that money comes from the frontline,” she says. “It comes from nurses and HCAs and doctors’ pay, and from drugs that don’t get purchased. You can’t run the NHS and expect it to perform if you flush the money out of the system, it just doesn’t work. We see this every day and it’s getting worse”.

The Conservatives are keeping very quiet about all this, perhaps wisely. With one hand Lansley and Hunt have enforced pay freezes on frontline staff claiming the pot is empty, and with the other, enforced an extortionate tendering process that has wasted vital funds. Just the cost of the top-down reorganisation alone, which a senior Tory MP recently described as the party’s “biggest mistake” in government, is estimated at £3bn.

On the pretext that the NHS is an egregious waste of public money – despite the fact that in 2012 the UK spent less on healthcare as a percentage of GDP than any other G7 country – the system has been altered from within. The result is a conduit to a £100bn-a-year pot with an NHS stamp on the side, which through some alchemy turns taxpayer money into private profits.

Stevens’ five-year plan is full of hope and some entirely sensible ideas to improve the system. But with no mention of any of the debilitating costs of running the new marketised system, which Unite head of health Rachael Maskell says could be as high as £1bn by the time of the election, nor the outcry from the profession about marketisation which the BMA itself is campaigning to see reversed in law, it seems a little hollow to say the least.

Benedict Cooper is a freelance journalist who covers medical politics and the NHS. He tweets @Ben_JS_Cooper.

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An Irish Sea border – and 3 other tricky options for Northern Ireland after Brexit

There is no easy option for Northern Ireland after Brexit. 

Deciding on post-Brexit border arrangements between Northern Ireland and the Irish Republic is becoming an issue for which the phrase "the devil is in the detail" could have been coined. Finding a satisfactory solution that delivers a border flexible enough not to damage international trade and commerce and doesn’t undermine the spirit, or the letter, of the Good Friday Agreement settlement is foxing Whitehall’s brightest.

The dial seemed to have settled on David Davis’s suggestion that there could be a "digital border" with security cameras and pre-registered cargo as a preferred alternative to a "hard border" replete with checkpoints and watchtowers.

However the Brexit secretary’s suggestion has been scotched by the new Irish foreign minister, Simon Coveney, who says electronic solutions are "not going to work". Today’s Times quotes him saying that "any barrier or border on the island of Ireland in my view risks undermining a very hard-won peace process" and that there is a need to ensure the "free movement of people and goods and services and livelihoods".

The EU’s chief Brexit negotiator, Michel Barnier, has made dealing with the Irish border question one of his top three priorities before discussions on trade deals can begin. British ministers are going to have to make-up their minds which one of four unpalatable options they are going to choose:

1. Hard border

The first is to ignore Dublin (and just about everybody in Northern Ireland for that matter) and institute a hard border along the 310-mile demarcation between Northern Ireland and the Irish Republic. Given it takes in fields, rivers and forests it’s pretty unenforceable without a Trump-style wall. More practically, it would devastate trade and free movement. Metaphorically, it would be a powerful symbol of division and entirely contrary to the spirit of the Good Friday Agreement. The Police Federation in Northern Ireland has also warned it would make police officers "sitting ducks for terrorists". Moreover, the Irish government will never agree to this course. With the EU in their corner, there is effectively zero chance of this happening.

2. Northern EU-land

The second option is to actually keep Northern Ireland inside the EU: offering it so-called "special status". This would avoid the difficulty of enforcing the border and even accord with the wishes of 56 per cent of the Northern Irish electorate who voted to Remain in the EU. Crucially, it would see Northern Ireland able to retain the £600m a year it currently receives from the EU. This is pushed by Sinn Fein and does have a powerful logic, but it would be a massive embarrassment for the British Government and lead to Scotland (and possibly London?) demanding similar treatment.

3. Natural assets

The third option is that suggested by the Irish government in the Times story today, namely a soft border with customs and passport controls at embarkation points on the island of Ireland, using the Irish Sea as a hard border (or certainly a wet one). This option is in play, if for no other reason than the Irish government is suggesting it. Again, unionists will be unhappy as it requires Britain to treat the island of Ireland as a single entity with border and possibly customs checks at ports and airports. There is a neat administrate logic to it, but it means people travelling from Northern Ireland to "mainland" Britain would need to show their passports, which will enrage unionists as it effectively makes them foreigners.

4. Irish reunification

Unpalatable as that would be for unionists, the fourth option is simply to recognise that Northern Ireland is now utterly anomalous and start a proper conversation about Irish reunification as a means to address the border issue once and for all. This would see both governments acting as persuaders to try and build consent and accelerate trends to reunify the island constitutionally. This would involve twin referendums in both Northern Ireland and the Republic (a measure allowed for in the Good Friday Agreement). Given Philip Hammond is warning that transitional arrangements could last three years, this might occur after Brexit in 2019, perhaps as late as the early 2020s, with interim arrangements in the meantime. Demographic trends pointing to a Catholic-nationalist majority in Northern Ireland would, in all likelihood require a referendum by then anyway. The opportunity here is to make necessity the mother of invention, using Brexit to bring Northern Ireland’s constitutional status to a head and deal decisively with the matter once and for all.

In short, ministers have no easy options, however time is now a factor and they will soon have to draw the line on, well, drawing the line.

Kevin Meagher is a former special adviser at the Northern Ireland Office and author of "A United Ireland: Why unification is inevitable and how it will come about"

Kevin Meagher is associate editor of Labour Uncut and a former special adviser at the Northern Ireland office.