Mismanagement as a prelude to privatisation

of the UK NHS

On June 30 The Guardian newspaper reported that the Commercial Directorate of the UK Department of Health had placed an advertisement in the Official Journal of the European Union inviting expressions of interest in managing the purchase of clinical services from health-care providers in the UK. The intentions of the UK Government have now been made abundantly clear. The advertisement was subsequently withdrawn to correct “a drafting error”, but this apparent gaffe should make it blindingly obvious to all who were not previously aware that the National Health Service (NHS) is being rapidly, cynically, and deceitfully privatised. The repeated assertions to the contrary by the latest ministers of the UK Government, Patricia Hewitt and Lord Warner, are no more than that—assertions that convince few who have anything to do with either the delivery, or receipt, of health care. As a former Secretary of State for Health of the Labour Government, Frank Dobson, is reported to have said, “If this is not privatisation of the health service, I don't know what is”.

The whole structure of the once great NHS is now a worm-infested sham—a crumbling edifice which consumes increasingly vast sums from the national purse while delivering a service which is progressively shoddy. The NHS was once a phenomenally successful institution which came close to providing first-rate care, day and night, to all—rich and poor, in home and hospital. It was once the envy of much of the rest of the world. The NHS was also remarkably cheap. It harnessed the underpaid professionalism and dedication of health-care professionals and ancillary workers, and was administered by a minimalist system of management. Today's NHS is a shadow of what it was, with the attention of general practice distracted away from the provision of clinical care by constant reorganisation, while those in failing hospitals are demoralised to the point of despair—abused, threatened, and hampered by armies of non-clinical staff whose increasingly obvious role is not to facilitate the care of the sick and needy, but to implement the directives of central government. The purpose behind those directives is privatisation.

The process of privatisation was started by Margaret Thatcher and private, or insurance-based, health care has presumably been adopted as the solution of choice by those in the present government who share her blinkered philosophies, and equally blinkered desire to emulate the USA, while actually having little insight into the reality of managing disease. Privatisation is also a convenient formula for isolating government from the cost of providing a health service, as well as from the blame when things go wrong. But those who work at the coal-face know that private systems work well only for the rich and for those with single-system disease. They work badly for the impoverished and those with chronic or complex disabilities. However, the move to privatisation is being driven not just by misguided adherence to divisive ideology, but also by the perception that something drastic must be done to tackle the appalling cost of today's NHS. How has the NHS come to such a dreadful pass? How has its management been so poor that it has become so dysfunctional and expensive?

The original move to destroy the pillars of the welfare state was mainly philosophical, albeit linked to the desire to reduce public expenditure. The NHS itself was not overspent, and actually accounted for far less of the gross domestic product than that in many other nations. However, the imposition of the new contract for general practitioners in the late 1980s introduced the concept of competition into health-care delivery, with some doctors being offered ridiculous financial inducements to adopt what was called fund-holding. They had the option to use NHS money to purchase care (from either NHS or private hospitals), and this was linked with the need for NHS hospitals to divide care into commodities which could be sold and bought, while tacitly ignoring the fact that the vast bulk of NHS expenditure is on emergency care and the management of complex and long-term disability, for which there were no contracts.

This initiative was later scrapped but the whole process has recently gone almost full circle, with the currently all-powerful (but cash-strapped) Primary Care Trusts yielding the responsibility for purchasing clinical services from hospitals back to general practitioners. This move to practice-based commissioning has been interwoven with the requirement that those buying and selling services must ensure that full use is made of many new facilities under the private finance initiative, which have been commissioned and built (at great cost to the taxpayer), but without clear plans for the services they will provide. Negotiations over commissioning have consumed hours and hours of doctors' time in every hospital and general practice up and down the country—effectively preventing them from doing the work they are paid to do. But now it seems that this initiative—like so many before it—is soon to be aborted and the responsibility for commissioning (ie, allocating the money to run hospitals) is to be contracted out to private companies.

If there is one reason for the progressive decline of the NHS which has occurred despite repeated managerial restructuring, it is the failure of those in power to appreciate that there is a fundamental difference between a service and a business. A service is based on humanitarianism, while a business—like politics—is based on self-interest. Those who have tried to reduce the cost of running the NHS have used business methods, and the result has been failure. The departmental budgeting adopted by hospitals has placed an emphasis on cost and competition, rather than on collaboration and quality of care. And to run the business it has been necessary to employ increasing numbers of administrators—in both primary and secondary care. But the business was always doomed to fail, for the simple reason that there was no real commodity for sale and no real purchaser, and all that was being achieved was the exchange of debt. Costs began to spiral, but the only response by Government and the Department of Health has been to announce yet more restructuring and to appoint more administrative staff to implement an increasingly savage programme of cost-cutting.

It is not just the edifice of the NHS that is being destroyed, but the professionalism of the people it employs. Managerial failure of monumental proportions has been justified by putting the blame on front-line clinical staff for failing to work efficiently. And yet these same clinical staff have actually been doing their utmost to preserve the service, despite the crippling financial and managerial constraints placed on them. They retain the professional (and legal) responsibility for the quality of care, while having little power to influence that which is being administered. They witness daily the decline of clinical standards, triggered by inability to cope with the steadily increasing work-load. They witness daily the staff reductions achieved by not renewing the fixed-term contracts of some of the lowest (in terms of salary), but hard-working and completely dedicated, staff. They witness daily the cynical use of staff re-grading (Agenda for Change) to downgrade clinical staff to remove the salary increments that were otherwise due in the following financial years. They witness daily the demoralisation of the good caring people on whom health-care depends, and when these people are demoralised, they leave, and their posts are frozen. Those who remain behind are told that they have to make do—not that they have to work harder (which would be politically incorrect and a potential breach of contract), but that they have to work “differently”—more efficiently. And all of this has had to be endured in a climate of complaint encouraged by Government and thoughtlessly echoed by the press, and therefore adopted by the general public. The result is that clinical staff who have hitherto said little are now getting to the limit of what they can endure. Not only are increasing numbers of ancillary and professional staff leaving, but—much more seriously—it is apparent that doctors and nurses are coming dangerously close to losing the principles of care and dedication which were once so deeply ingrained. Some are even setting up businesses themselves. Who can blame them?

But the NHS is not yet irretrievably doomed. There is no reason at all why a first-rate, centrally funded national health service is not viable in this day and age. It would, and sadly probably will, be very viable when run by the private companies currently being courted by the Department of Health. Private industry will be well aware of the root cause of the problem and will promptly dismiss all those serried ranks of administrators and middlemen (and middlewomen) who contribute nothing to the process of health care. Private industry would not invest in cock-eyed new schemes when they were failing to deliver on their core service. Private industry would not abuse its clinical workforce, but would encourage them—because proper businessmen realise that the workforce is the principal asset on which good service-delivery depends. Given this, many would think that privatisation might not be such a bad option after all. This would be undoubtedly true if it were not for the fact that a health service which is privatised (overtly or covertly) will: cost more, because the purpose behind providing improved care will not be humanitarian ideals but profit; and be rationed, and not always available to the disadvantaged. This is the crying tragedy that underpins the whole process: the NHS could be saved, but only if there is a real desire to do so, and only if the task were tackled with clarity of thought, planning that is independent of any personal conflict of interest, and ruthlessness of implementation. Apart from the ruthless aspect, this is probably an impossible task for the politicians and mandarins who are currently charged with the job. But if the British public want to retain the principles of the NHS, and to see it flourish once more, then they should understand that this is the only option. If the politicians and mandarins currently in post cannot be trusted to do what is required, then someone else should do it.
William Jeffcoate, Lancet, Volume 368, Issue 9530 , 8 July 2006-14 July 2006, Pages 98-100