The Beginning of the End: for the National in the NHS?

Dr Jacky Davis, co-author of recently published NHS For Sale – Myths, Lies and Deception, warns of the dangers of local devolution of health budgets against a background of underfunding and incoherent accountability.

AFTER FIVE YEARS OF RELENTLESS NHS DEMOLITION you might have thought that the Con Dem Coalition could no longer shock us when it comes to the NHS, but recent events have proved otherwise. Out of the blue it has been announced that sweeping changes are about to take place in Greater Manchester, where ten local councils will take over the combined health and social care budget (£6bn) in a massive devolution of NHS services.

The NHS blogosphere has been humming with denunciations of the changes, with only a few defending them. Those who approve hope that the changes will lead to more joined up local services and a possible reversal of the drive to privatisation where Labour is in power. They also fear the evils of EVEL – English Votes for English Laws – which could in future threaten the domestic programme of a Labour government which had a UK majority but was at the mercy of a Tory majority in England. They see the devolution of the joint health and social care budget to local authorities as a possible way of pre-empting this.

Those who oppose the proposals have a much longer list of concerns. The first is to wonder why the process has been so deeply undemocratic, stitched up behind closed doors and then sprung on an unsuspecting world. There has been little or no evidence of health workers or the public being consulted, and rumour has it that a public ‘consultation’ lasted three weeks and attracted twelve responses, ten of which came from those who had a hand in the agreement. Local GPs outside Clinical Commissioning Groups were apparently kept in the dark and Dr Tracey Vell, chair of the Manchester Local Medical Committee (which represents GPs in the area), told a reporter that “general practice as a provider has not been given a stake so far in the process.” It is a real shame that the local councils have gone along with it. And the lack of democracy involved in getting this proposal agreed does not bode well for how local politicians will run the system.

NHSThe next big concern is the bringing together of two underfunded budgets, combined with the fact that social care is means tested whereas NHS care is not. There are already reports of care that used to be delivered under the NHS being rebadged as social care with consequent threat of charges. In SE London for instance, where childhood vitamin D deficiency and rickets is on the rise, the vitamins needed to prevent this are deemed to be social care so they are means tested and charged for. Under these new arrangements this mission creep is only likely to get worse.

Local authorities have suffered real terms funding cuts of 20% in five years and are already on their knees. Instead of bringing social services up to the level of protection which the NHS has, local authorities may be forced to sacrifice health services to shore up social care and to find ways of charging those who need services. Tying two sinking boats together won’t make both of them seaworthy.

Local authorities have no “duty to provide a comprehensive health service”, nor do they have much in the way of ‘in house capability’, so it seems inevitable that giving the NHS and social care budget to them will lead to an increase in outsourcing (Barnet council in London for instance has already outsourced almost all of its services). Since the trend has been for private companies to win the contracts in the areas typically involved, (according to an article in a recent British Medical Journal, they are already winning two thirds of mental health and community contracts), there is likely to be a further acceleration of privatisation of the NHS and related public services.

For example there are already reports of local authorities which have wreaked havoc with sexual health and substance misuse services. In a recent letter to the Guardian the former clinical director of a drug and alcohol service described the problems after it was transferred to a local authority in 2008. It became fragmented and largely transferred to private sector providers due to the requirement in local government that all services are put out to competitive tender every three years.

He went on:“This pattern has been replicated across the country; the NHS is left delivering substance misuse services in no more than a handful of areas. What was once a vibrant and effective sector of the NHS built on a stable and committed workforce is now a patchwork of local private-sector providers who are subject to recommissioning every three years. Morale among the workforce has never been lower and services rely in the main on the deployment of poorly paid agency staff. Those of us lucky enough to have found a way out watch with great dismay from a safe distance. Is this what we want for the future of health provision in Manchester?”

Finally, given the timing it seems highBurnettly likely that there is also political skulduggery at work. The upcoming election is the most unpredictable for a long time, and it looks as if the jostling for position in the event of leadership challenges has already begun. If Cameron has to be sacrificed after a poor result, then Osborne many be hoping that this deal will help his chances by making him look like a champion of the NHS (he must think we have very short memories!). At the same time, some in Labour may not be sorry that Andy Burnham was discomfited by this move, given that he would be a strong contender in any post-apocalypse Labour leadership scrap.

If health and social care are to be integrated there may be advantages to devolving decisions down to local level, but not in a piecemeal manner and not in the context of current NHS legislation. The way forward would be to bring health and social care together at national level and under a national NHS budget (as Scotland have done), and for both to be properly funded. And if politicians want to do this, they should put it in their manifestos and allow voters to decide.

Meanwhile the local population in Manchester are so unimpressed with the decision that there is already a march and demonstration planned for the end of this month. One thing is for certain – if George Osborne is signing off the deal with a big smile, we should be very worried indeed.

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