Lord Warner, former health minister under Tony Blair, is set to release a book next week entitled, ‘A Suitable Case for Treatment’. It is his opinion on why the health service in the UK should embrace market-based reform. Yesterday, the Guardian published a synopsis, so here it is with our Big Society take.
Lord Warner is renowned for speaking his mind and in 2009, when Gordon Brown was pushing through the policy of free, personal care at home, Warner branded it a “cruel deception“. There were issues on affordability and delivery of the plans and worries it would decreases the numbers applying for means-tested residential care. However, many elderly patients and their relatives would rather that they were able to stay at home where they still have a sense of independence and comfort.
The acute sector, he argues, is clinging to a model of care that is wholly out-dated for the ageing population. “Stacking significant numbers of 85- to 90-year-olds, largely women, in the medical wards of acute hospitals doesn’t seem to me an appropriate clinical business response for this day and age,” he says.
Urging a big shift towards more care of older people in nursing homes, which is far cheaper and away from the threat of hospital-acquired infections, he adds: “Many more could be in single rooms in nursing homes, being nursed and managed more safely than on bayed wards in hospitals.”
This is good in theory, except that cuts to social care have reduced the availability of spaces in care homes for the elderly, leaving no option for some other than to go in to hospital.
He acknowledges that Labour “saved” the service, but laments the “serious mistakes” he believes it made including: failure to achieve effective commissioning of healthcare, allowing excessive expansion of the workforce, thus worsening productivity, and ignoring the challenges of replacing underperforming and unsustainable hospitals and other service providers.
“Having given people a reasonable chance to remedy their defects,” he says, “you have to be able then to remove them and let some new players come in. Whether they are from the NHS, social enterprise or the private sector, I don’t think I care.
“But one of the things I do care about, which is one of the reasons for writing the book, is just allowing failure to carry on, taking taxpayers’ money and giving lousy services to the public. And many of those lousy services are in the poorer areas: the sharp-elbowed middle classes usually find some way to cope with the problem.”
By this I’m unsure if he thinks that the government, public and health practitioners alike are happy for services to be substandard. No-one likes health inequalities. Sir Michael Marmot’s inequality review points to the large inequalities between social classes within the UK, which is something that drastic reforms will play little part in adressing. Another point is that price competition tends to increase health inequalities and worsen health outcomes.
- Wants to see that the coalition is serious about penalising failure.
- Would like tougher financial management regime for the new-look NHS.
- Intends to table an amendment to the reform legislation in the Lords, proposing a financial management standards board sitting within the NHS commissioning board which draws on outside expertise.
“No one else in the world would be running an £80bn or £100bn business based on the kind of appalling financial management we have in the NHS,” he says. “It’s a very curious state of affairs to be expending that amount of public money on something where, on the whole, we don’t know the costs of goods and services and we certainly don’t know the different costs between different providers.
“I find it difficult to see how you can have any kind of market of proper competition if you don’t have, in the public arena, a financial management system which delivers more and better information about the costs of goods and services.”
Again, I think we all care about how the money within the NHS is spent. Cost-effectiveness is increased with better management, use of NICE guidelines, and forward planning, not dramatic cuts to services which in the medium-to-long term increase expenditure.
“Simply increasing the influence of clinicians without changing the way the NHS does its business will not deliver desired change,” Warner concludes. “Without a more robust financial, economic and performance architecture, greater devolution and clinician power could produce financial meltdown …”
The evidence that GP consortia work comes from America, where there is privatisation and market competition. Andrew Lansley U-turned on price competition a few weeks ago raising doubts over whether this system of commissioning will work.
In his opinion for GP commissioning to work there needs to be a willingness and capacity to “reign in” the acute hospital sector and switch resources into community health services and social care.
This is not a new idea. Community care for people at risk including those with mental health illnesses, elderly and disabled persons tend to have better health outcomes than those admitted acutely into emergency units. This also has the benefits of significant cost savings.
Other things that Warner would like to see include:
- are a fresh and strategic approach to managing the NHS estate,
- making better use of its land, buildings and facilities,
- end to national pay bargaining to allow flexibility in local labour markets.
The latter of these, despite his previous claims of wanting to reduce inequalities in health, will create mass movement of health care professionals to where the pay is greatest, the best physicians will get these posts and inequalities will increase enormously, benefitting those in areas where there is a wealthier population and disadvantaging those in the lowest economic classes.
He likens the possibility of market competition in the NHS to that which was experienced to other public services, such as the rail network and water, in the 1970s and early 1980s. “They were forced, brutally, by Thatcher to start looking outside for some of the solutions to their problems. It’s not about handing stuff over lock, stock and barrel to the private sector; it’s actually getting on your bike and going to look at how other businesses do their business.”
In theory this is good practice to lower costs. But some of the poorest areas of the country have ended up paying over and above the odds for their water and sanitation services. So would those who live in areas where there are high levels of co-morbidities have fewer services as a result of local privatisation and an attempt by consortia to balance the books?
Much of this has been said before, but the government needs to be looking at the evidence, looking at our own country’s history of privatisation and learning from previous mistakes that former governments have made. If you think that there should be an evidence base for all the decisions being made then sign the petition and write to your MP using our draft letter.