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Kailash Chand

Retired GP and PCT chair. A health campaigner and founder of 'Drop the NHS bill E-petition', he was given an OBE in 2010 for services to the NHS.

The reforms of the NHS, as instigated by the coalition government, continue to dominate the health agenda even in this implementation phase.  It is worrying that a number of unintended consequences of the health reforms are becoming clearer e.g. A & E crisis.  As implementation of the Health and Social Care Act unfolds, we see that the debate on the future of the NHS is not over. If only the Government had truly listened when doctors, nurses and others were urging caution during the passage of the legislation.

 The idea of Andrew Lansley’s reforms being patient centred and empowering clinicians could have been initially described as a noble one. But we have to ask whether these have gone the way anyone, on either side of the political divide, would have liked?

 And where is the NHS is now heading?  An uncertain future in my view.  Concerns over the Health and Social Care Act have not diminished – certainly within the BMA, we continue to press the case to Government that evidence-based implementation is absolutely essential for the benefit of patients first and the staff that hold the NHS together. 

 What is unavoidable in the NHS’ journey is the fact that money – or more accurately the lack of it – will be a major consideration.  Quite frankly,  whatever structure exists for the NHS in the future, it will need to get to grips with a tighter financial environment whilst trying to ensure that quality of care is not compromised within the context of new advances in technology and a society that is living longer.

 I will now focus on two particular areas of the NHS reforms that are causing huge concern  because of fears for what they could mean for the NHS long-term.  The first is the uneven establishment of CCGS(Clinical Commissioning Groups) and the second are the effects of the dogmatic reliance on pushing market forces within the NHS – something I personally feels threatens its very ethos and survival. 


Clinical Commissioning Groups

 During the passage of the legislation much prominence was given to clinicians so that they take greater responsibility for commissioning care. However it already seems that this key plank of the reforms is off to creaky start.  The idea of clinically led commissioning was always laudable. Could anyone at the time really disagree with doctors having more control to shape services for their patients?

 We are hearing worrying reports that some CCGs have developed inappropriate constitutions and have pressurised GPs to ‘sign up’ to these documents. And in the process, GPs are becoming increasingly disillusioned in the development of their CCGs.

  This issue is important as the relationships between member practices and CCGs in these stages of development will determine the level of genuine, wider clinician involvement in commissioning decisions in the future. There is a risk that as GPs become increasingly disillusioned, the new structures will simply replicate the old (at huge expense), with no sense of ownership amongst the wider profession for the decisions being taken on their behalf.

 Should my fears be confounded then we are on a long and unknown path that could see these groups in five to ten years continue to operate without the necessary involvement and engagement from GPs up and down the country. Without this, can these groups ever do what they originally set out to achieve? Or will we see by 2017 a series of groups that are operated by an enthusiastic minority, disconnected from and unaccountable to the rest of the profession; disheartened GPs and a health service that is struggling with its organisation.


Market forces

 Another major concern I have for the immediate future of the NHS is what impact further encouragement of the market within the NHS will have – the Act pushes ahead with this as it roots in a full blooded system of economic regulation in the NHS. 

 Although there has always been some role for commercial organisations in the NHS, manufacturing drugs and equipment for example, I am very concerned that the more we move towards a model which encourages profit-making companies to compete with NHS providers, there is a real threat that local health economies could be destabilised – something we really can’t afford to risk happening.

 I am very worried about the over-reliance on this lever – an over-emphasis on competition will hinder integration and collaboration.  Better coordination between different parts of the health service is unlikely to be achieved when the health system relies on market forces and providers are competing with one another.  Competition will lead to valuable time and money being spent on bureaucracy managing competition rather than delivering care to patients. 

 There are many examples of where use of market reforms in the NHS has not been successful. The Private Finance Initiative where private money is borrowed to fund hospital developments has left many hospitals struggling to pay off the debts and huge amounts of taxpayers’ money was wasted when Independent Sector Treatment Centres were paid hundreds of millions for operations that they did not carry out.

 And more recently, Any Qualified Provider, which on the face of it seems to be about choice, is really yet another lever that could actually lead to more fragmented services for patients. 

 Surely, that is not the sort of picture we would want to see in the future.  

 It is time to reject the market ideology that has plagued the NHS for more than 25 years and wasted billions of pounds in the endeavour to get more of the NHS budget into the hands of private companies.

 Instead, like the Scottish, the Welsh and the Canadians, we should  move forward with a publicly funded, publicly provided, publicly accountable healthcare system based on co-operation, collaboration and the social contract between doctors and patients.

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