Talk about the NHS “reform agenda” and you end up knee deep in a flood of acronyms and abbreviations. Below we try to define what some of them mean. Our definitions are hopefully more to the point than DoH (Department of Health) circulars which prefer to hide the detail of what’s going on by using a private language of “modernisation’
EBP-Evidence Based Practice.
All clinical interventions must be justified on the basis that they work and are backed up by research and other evidence.
All drug treatments, operation techniques, talking therapies etc must have been proved to have an effect and are safe before they can be used.
This means that many “alternative therapies” such as homeopathy which don’t have scientific backup will not be funded. If a doctor or nurse uses them, they could be struck off. If such things work at all, it’s because of wishful thinking, the “placebo effect”.
But most of the following reforms such as PFI have no evidence base, and the governments belief in them is based on the idea that the private sector and the market are better than public services. Despite growing evidence demonstrating that they don’t work, they are being persistently pursued. Applying their own prinicples to ministers would mean bringing a case of “gross clinical negligence” against them.
Foundation Trusts. Once upon a time there were hospitals under the control of local communities and health authorities. Then they became trusts, one half of the provider-purchaser split, accountable to the Primary Care Trusts who commission their services.
Foundation Trusts are a further step towards making hospitals/ secondary care into independent business units responsible for their own finances, as long as they are financially viable and able to raise funds directly from the private sector. This financial independence allows them to start competing for contracts to deliver services previously provided by other hospitals. It will also allow them to start negotiating local terms and conditions for workers, so undermining national agreements.
ISTC-Independent Sector Treatment Centres. Despite the use of the word “independent” and their supposedly “complementary” relationships to NHS hospitals, these are basically private hospitals performing simple, low risk operations in bulk. Or that’s what they are supposed to do. Unlike hospitals inside the NHS, they are paid up front at rates above the national tariff and keep the money whether the operations are done are not. Last year they fell short of their contracted operations by 50,000. Nevertheless they will receive £1.4 billion of public money on their existing contracts.
LIFT-Local Improvement Finance Trust. Basically PFI for primary care. New GP surgeries etc are being built under this scheme.
National Tariff. This gives the guide price that local PCTs will pay to a hospital trust for carrying out an operation for example under PBR (payment by results). Of course working from an average means smaller hospitals are losing money as they aren’t as efficient as the big teaching hospitals. They complete fewer operations, and costs are higher. So despite providing a decent local service they are penalised by this new system.
NICHE (Previously NICE) - the National Institute for Clinical Effectiveness. This organisation is meant to test new treatments and their cost effectiveness in an objective scientific manner, in line with the drive for EBP.
However they have been charged with fiddling their figures and are open to external pressure particularly from the big drug companies. On one occasion they concluded a new drug was ineffective and shouldn’t be used only to change their mind under government pressure when the company threatened to pull out of the UK.
PCT-Primary Care Trust. These continue to provide local community based services such as GPs, District Nurses etc, but they now have a commissioning role buying services from secondary care (hospitals). They spend the vast majority of the NHS care budget and are of great interest to the private sector keen to pick up this commissioning role on a tendered basis. When this happens, private sector commissioners tend to opt for private sector providers rather than public services, so boosting the private health care sector.
PBR-Payment by results. This is the heart of the new funding system and the basis of the internal market. The main effect has been to raise the admin costs of the NHS to something near 20% of the overall budget, £20 billion in England, as everything now has to be costed, counted and invoiced. That’s compared to the 5% annual admin costs of the old “bureaucratic” NHS.
PFI-Private Finance Initiative. Originally a Tory idea, this is the main source of funding for all new hospitals etc. It’s also found in education and other areas of the public sector. Money for building is raised by the private sector working alongside a contractor who does the actual building. This is at an interest rate much higher than the government would pay on its own borrowing. The private contractor takes over the servicing of the building, meaning porters and cleaners leaving the NHS. So far the private sector has put in £15.5 billion. At the end of the contracts they will have received £90 billion in repayments.
There are other elements of the “reform agenda” that we can’t go into here. Taking together, all the above mean the government are directly handing over sections of the existing NHS to the private sector (NHS Logistics last year and the National Blood Service soon); preparing other parts such as the PCTs and Foundation Hospitals to float free of NHS control; and funding the creation of a parallel private system of healthcare (ISTCs etc).
The end result will be the breakdown of a national system and the recreation of healthcare inequalities, with specialist services only to be found in a few regional and national centres. Big hospitals will swallow up smaller ones and then asset strip them as the motivation changes from providing a universal service to producing a profit. Overall the effect is to make health a commodity, something to be bought and sold.
The introduction of charges for seeing a GP and other services is being discussed, as is the need for everyone to have some private medical cover.
Having successfully undermined the principles of a public pension system without any fightback from the unions, the government is quite confident of getting away with it.
This process has already been seen through in social housing. It is underway in education and social services. It means a rolling back of the gains of the 1945 “welfare state”. Imperfect as they were by the standards of working-class socialism, they should be defended as against a market system unrestrained where misery, poverty and illness are opportunities for profit, not evil giants to be slain.