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Guest Editorial Monday 13 December 2010: The new provider Lansleyscape

Irwin Brown of the Socialist Health Association wonders how a provision-led NHS will cope with a John Lewis future of unlimited choice and competition. Will tastefully-made TV ads be enough?

Could we stop worrying about commissioning for a bit, and worry about what is happening in provider world?

Of course we and the Treasury worry about £80bn of public money going to a variety of quangos with no relevant experience and without accountability.  But most of that money is actually spent in provider organisations, where it translates into jobs, drugs and very little rock and roll.

The White Paper vision for providers is they will all be John Lewis or other forms of private sector organisations.  Big societies, mutuals, staff ownership, co-operatives and no doubt the local brownie troupe all feature in this highly fragmented version of the provider landscape. They will compete and be paid based on “outcomes”, in some undefined way.

I would like to see a contract based on something you cannot define or measure properly!  

The post-planning age
Crucially there will be no providers who are actually part of an NHS of any sort.  There will be no need for capacity or service planning; no need to design products (pathways);, no need to plan for the future workforce; the invisible force that is the market sorts all that out.

There will be no management of the NHS as such, the all powerful regular (OffSick) will ensure proper competition and will step in if any improper activity goes on – like a GP talking to a consultant.

If there is not enough competition for any service, then it will be stimulated through the usual process of offering thinly-hidden “bribes” or sweetheart deals to new providers, obviously from the private sector.

The magic of the market
If organisations go bust, there is to be no bail-out option and yet, through some form of market magic, no interruption in providing services – but no bail-outs, ever, not at all, not no how. Just like the banks.

Once we get all this market stuff in operation, we will no longer need an army of bureaucrats in the Department and its SHA and PCT outposts – and actually we won’t need any GP Consortia or other species of commissioners either, the market makes them irrelevant.  And here we might all cheer … but read on.

So we have a plethora of providers of all shapes and sizes but all in the private sector – even if they are social enterprises – which sit alongside Big Society as being part of any speech made about the NHS but being beyond reasonable definition.

They will be free to treat as many private patients as they can, who presumably would expect preference.  They will have their own terms and conditions of employment; Agenda for Change will wither, die and be mourned when a deluge of comparability claims engulfs the tribunal system – unless that too is abolished as anti-competitive.

Who owns the assets, the £billions tied up in buildings, plant and machinery, and who gets lumbered with ludicrously expensive and inflexible PFI contracts has yet to be decided. However, the intention is to get rid of public assets – get them off the public balance sheet.  

Choose life. Choose services, choose an interventional radiologist, choose a porter …
This is an extreme consumerist vision of choice for everything.  In LaLa Land, every patient can choose which provider they want at every stage in their journey of care; each time you feel the need to see a GP consult the Find A Really Good GP website and take your pick.

And if, part way through your rehabilitation, you tire of the banter from the therapist? Simply thumb through the alternative therapy section of yellow pages and take your pick.  Or as you lie broken and bleeding at the side of the motorway, waiting for the ambulance of choice, you can use your iPhone to Google info on local trauma units.

As the Welsh know, the end of the NHS as we know it does matter. Even if the market system could allow a ‘free at the point of need’ NHS system to continue, which is unlikely, the emergence of co-payments and additional payments would be inevitable.  You can have the basic NHS paid for service or, for just £X, Plans A, B, or C which give extras, like a better room, shorter waiting time or free travel to any from your chosen hospital.

’Nobody is saying choice is wrong or that competition is always bad, but both must have some limits.'

And of course there will be an increasing set of services on offer which can ONLY be accessed through private payments. Private providers will become expert at cost shifting into social care - which means the patient will be charged for it or subjected to means testing and intrusive forms of assessment. (They might vote for this in Essex.)

Nobody is saying choice is wrong or that competition is always bad, but both must have some limits - and actually the public out there understand this and accept it, unless they live in Essex (and maybe Cambridge).

Involving patients in their care and offering choice over treatment options is good for all; offering choice between NHS providers is fine too.  Taking action when it is clear that standards are falling is also right - but it should not take patient choice to indicate failings - that is far too late.

Yet that is how a market operates - the bad get worse until they fail economically.  We already have markets for some services and choice, for example for routine elective surgery, but do we want a total market system – does it even make sense?

Most patients still want to go to a local setting and expect the NHS logo to be the kitemark which guarantees good care.  As better information becomes available there will be those who do assess possible providers and make choices and this trend can only increase, but for the foreseeable future this will be either manageable or marginal.

But the marketeres want exactly the opposite; they want choice to destabilise the system so it forces change.  They want new organisations coming in and old ones closing down; they want all the risks transferred to us as patients.

Breaking up our NHS into a series of private, independent, unaccountable, competing providers does matter and it ought to be more prominent in the current debate. This is privatisation.

Do we want an NHS which values involvement, partnership and co-operation and some kind of strategic planning - or not?

If we can’t get more sense into the Bill, then our really big choice will have been taken away.