You can't get better...

O.K. so it's not quite the speedy revival I was hoping for. Still perhaps if I aim for a post a month for now that will do? Well it might have to. And to be honest I'm not sure you're going to like this one. Still here it is...

This week saw the publication of the Health and Social Care Bill, the road map for the much heralded changes to our health services in Blighty under the present administration. You'll notice I've omitted the word National and the capitalization. The thing is, it's hard, sitting here, to see the coming changes as anything other than the final nail in the coffin, ending the pretence that we have such a thing as a unitary "National Health Service" at all.

Ever since devolution, health in Scotland, Wales, and Northern Ireland have been devolved too (in fact the Scots had their own service even before that), but these four separate services still cannot really be regarded as truly national even within the definition of the "home nations" that make up our fractious little "United Kingdom".

Even before this the rot had started with the experiment that was "Fundholding" where GPs held a tiny proportion of the NHS budget to buy operations for their patients from hospitals. The vast majority of these operations were still performed in the NHS (soi disant) but already the "internal market" had hospitals (later "Trusts") vieing with one another for the cash. And even then a small proportion of procedures were shuffled sideways to the private sector on the basis that they could be done quicker and at no more cost to the taxpayer.

This hypocrisy was swallowed hook line and sinker by the monster that was the incoming faux "Nu" Labour administration. Competition and choice became holy writ, and so they remain. True, levels of investment in health went up, and at last we reached a level comparable to other developed economies. Sadly that increase was built on the foundations of decades long underinvestment, so although current spend might be comparable, past investment has been anything but and our infrastructure remains woefully inadequate as a result. Worse yet, dear Gordon found a splendid way of burying the cost of new infrastructure in the PFI scheme where we, the humble taxpayers, sign up to a 30 year mortgage every we time we want a new hospital / surgery / clinic, and said facility is built, operated, and owned (for gods sake) by private enterprise. So not so much mortgage as "rent" then. And at the end of the 30 year term what happens to the infrastructure? (No that's not rhetorical-- I'm pretty sure the builders will own it and our successors will be renegotiating the lease, but I'm not 100% sure).

Oh but then there was even worse to come. ISTCs anybody? Well some of you might have been treated in one. Most PCTs have one. Remember our old friends choice and competition? Well to enshrine them in our hearts PCTs were compelled to establish Independent Sector Treatment Centres. Yes Independent Sector-- "Private" to you and me. Set up by the NHS and awarded fat contracts for surgical procedures and outpatients. They bussed in Consultants from far and wide. Mostly from the expanded EU and Scandinavia, all thoroughly decent chaps and impeccably qualified, but with no grounding in the workings of the NHS. They were guaranteed income for operations and creamed off all the "easy" cases. They did good work, but on fitter, younger, less complicated patients. Anyone who crossed their threshold with a sniff of a raised blood pressure, wheezy chest or high blood sugar was politely declined and sent back to wait for the NHS "proper" to sort them out. And remember the "guaranteed contracts"? Well they meant that in a year when they didn't perform the required number of procedures contracted, they got to keep the money anyway. And all paid for by the PCT and therefore the NHS. And if, and when one of their patients did become more complicated, they were shipped out of the ISTC and back to the local hospital to be sorted by the NHS consultants who had been denied the opportunity to treat their initial problem by the establishment of the ISTC.

Add to that the lunacy of ever more micro-management of contracts and setting of targets as Nu Lab imploded and our poor PCT colleagues have spent much of the last five years running around in ever decreasing circles. And now we get the Health and Social Care bill. Where once we had fundholding, now we get GP Commissioning, and instead of 10% of the NHS budget we get something approaching 60-70%. We're still mortgaged to the hilt with hospitals we don't own, and now every "provider" of NHS services is going to be compelled to become, or to join, a "Foundadtion Trust". Where prices for specific treatments were set nationally now these trusts will be at each others throats striving to win contracts, and now we get the added imperative to consider, when contracting, "Any Willing Provider". Until now the assumption in contracting has been that the NHS family is the "Preferred Provider" and so when bidding for contracts for NHS services, Trusts could presume their bids would be considered ahead of any other. Now that protection is gone and not only will thrusts be at one anothers throats, they will do so with wolves circling the fold ready and waiting to pick off the choicest prey.

And the best bit, the absolute best bit... PCTs (the health service managers we've all derided for all these years, but who have done the best they could to shield us from the twin madnesses of the Department of Health and the Foundation Trusts) have been told that they must continue to run the show for the next year or so whilst GPs gear up to becoming managers themselves, knowing that at the end of their term, they will vanish. Some will doubtless be reabsorbed into the new commissioning bodies or the overseer NHS Commissioning Board which will be there to insure the Commissioning consortia are working properly. But with massive cuts in funding for NHS management demanded throughout the restructuring, many more will be looking for jobs elsewhere, just at the time the Private Sector "wolves" are seeking a foot in the door.

The NHS I joined in the early 1980s gave me freedom to refer patients anywhere in the system, based on their need as that system was bought and paid for in its entirety as a monolithic state run enterprise. Since the foundation of the PCT my freedom to refer has been constrained, in large part, to the county I work in, and to the two or three Trusts my PCT contracts with and preferably to the hospitals we are shackled to by PFI contracts. With commissioning, all the early evidence suggests my freedom to refer will be constrained still further. "National" no longer applies. Even "Local" is beginning to look dicey. True for most of my patients, most of the time, this won't mean a lot. Right up to the point it means their hip replacement will be done by Kwik-fit as the cheapest willing provider!

16.ii.11 Addendum.
In a similar vein just seen this which you might like to read. Not sure I agree 100% but there's some honest to goodness venting going on and much truth. (Thanks to BG for tweeting the link).