“I believe the creation of the NHS is one of the greatest achievements of the
20th century. I always believed this.”
— David Cameron (2006).
As part of the transformation of the Conservative Party away from its neo-liberal ties and towards a more compassionate form of conservatism, David Cameron prioritised the NHS and sought to protect and defend its core principles and values. This signified a fundamental shift in direction as the Conservative Party have historically been hostile towards the NHS, preferring instead private forms of healthcare (Baggott, 2011). Health policy under Cameron has developed significantly and the NHS, as part of the pursuit for the Big Society, is set to go through a number of changes in order to devolve more power to patients, local authorities and communities. This chapter will discuss the recent developments in health policy, focusing specifically on the Health and Social Care Bill 2011 and will analyse how the policy fits in with the Big Society agenda. The extent to which the policy signifies a fundamental shift in the Conservative approach to health policy will then be discussed using references to health policy during the last period of Conservative government (1979 – 1997).
The Conservative Party election manifesto Invitation to join the Government of Britain 2010, pledged to ‘Back the NHS’ and increase NHS spending every year. It also promised to give patients more choice and freedom within the system and to enable better access to treatments, services and information (Conservatives (a), 2010). The Coalition Agreement, Our Programme for Government, echoed the Conservatives’ pledges as the NHS was one of only two areas exempt from spending cuts, the other area being international development (Baggott,2011). Although David Cameron presents the maintaining of the budget as proof that he will not be making cuts, in reality the NHS needs increased spending merely to maintain current levels of services and therefore indirectly cuts are inevitable. The eroding effects of inflation means that the spending freeze essentially amounts to an indirect real-terms cut to the health budget of £20bn over the next 4 years. This highlights how during periods of austerity even the most treasured institutions, such as the NHS, are expected to make sacrifices.
The Conservative manifesto also proposed a number of initiatives aimed at reorganising the NHS to introduce even more competition into the system. The proposed changes to the NHS can be interpreted as the Conservatives following in their traditional pragmatic nature and responding to the current failings of the NHS which has been continually criticised for being overly “bureaucratic, centralised and disconnected from the people and communities it is supposed to provide for” (Gubb, 2011). In July 2010, the Coalition government’s plans were set out in the White Paper, Equity and Excellence: Liberating the NHS (DH, 2010) and proposals were based around four themes: creating a patient centred service; improving healthcare outcomes; increasing autonomy and accountability of professionals; and reducing bureaucracy to improve efficiency (Page, 2011). The proposals set out in the White Paper are also very much in line with the Big Society as to create a patient centred service the reforms will promote greater patient involvement and choice in health services. It is proposed that this will be achieved by allowing patients greater access to information and allowing services to be delivered by ‘any willing provider’ that meets NHS standards.
The use of ‘any willing provider’ appears to sum up the approach of the Conservative led Coalition government, as this was also used in the implementation of the Work Programme, discussed in the previous chapter. Much of the rhetoric here closely mirrors that used in the implementation of the Work Programme as discussed in the previous chapter. The use of any willing provider will further open up the NHS to market competition as both private and voluntary sector organisations will be able to deliver services. The Government expects this competition will improve healthcare outcomes, and a number of regulators, such as Monitor and The Care Quality Commission, will be used to ensure quality is maintained and remuneration to providers is regulated (Asthana, 2011). The further contracting out of services to other providers may firmly establish the Big Society in the area of health policy as there is scope for third sector agencies to provide services and create more diversity and locally based systems of healthcare. This therefore may represent quite a fundamental shift in the Conservative approach to policy as the focus is no longer on private healthcare provision, but appears to be somewhat supportive of voluntary agencies.
One of the biggest reforms to the NHS proposed in the White Paper is the creation of GP Commissioning Consortiums which alongside the NHS commissioning board will be responsible for commissioning services and treatments in their localities and deciding how best to allocate resources. This will allow for more autonomy and accountability to professionals and will also empower them to decide what services are best to serve the local communities, which again supports the idea of a move towards the creation of a Big Society, whereby services are tailored to function in a specific community and whereby power is very much located at a local level. The GP Commissioning Consortiums and the NHS commissioning board will however mean the abolition of Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs), which alongside a number of other quangos will result in more than a 45% reduction in NHS administration and management costs (Asthana, 2011). Although the restructuring of the NHS and the devolution of power to professionals and patients are all geared towards reducing administration and management costs, the restructuring is estimated to cost between £2bn and £3bn, which in a period of austerity seems to be a great amount especially when £20bn in savings must be found over the next four years and leads one to question whether such savings are really necessary.
According to some, in its current form the NHS fails to provide a high quality standard of healthcare and health inequalities continue to increase, reorganisation is therefore seen as necessary (Gubb, 2011). This concern for health inequalities and improvement for health services again highlights the compassionate conservatism adopted by the Conservative Party. Further evidence of the new compassionate conservatism can be seen in their manifesto pledge to ensure funding is directed towards areas which have the worst health outcomes (Page, 2011), it is hoped that this funding will also ensure quality and efficiency as providers will be paid by results (Asthana, 2011).
These proposals discussed are currently going through Parliament under the Health and Social Care Bill 2011 and have not escaped strong opposition and criticism. The health secretary, Andrew Lansley, has faced numerous accusations regarding what some see as the privatisation of the NHS if the Bill is fully accepted, however he and David Cameron remain adamant that the NHS is not, and never will be privatised (Peedell and Cook, 2011). The World Health Organisation however defines privatisation in healthcare as “a process in which non-governmental actors become increasingly involved in the financing and/or provision of healthcare services” (Peedell and Cook, 2011), which is arguably what will happen once services are contracted out to any willing provider.
Another key concern regarding the Bill is that the newly formed commissioning groups (e.g GP consortia), will no longer have the legal duty to provide the statutory services that the PCTs are currently required to provide. If legislation passes only ambulance services and emergency care will need to be legally provided which means that services in certain communities may no longer be funded by the NHS (Pollock et al,2012) . Therefore it can be assumed that people will have to turn to the private sector to get the healthcare they need, because, as discussed in Chapter 3, during the current climate third sector organisations are struggling to fill the gaps created by the spending cuts. Removing the provision of some services is argued by Pollock et al (2012 ), as a way of allowing charges for certain services to be brought into the NHS, which goes against the very core principle of the NHS being healthcare which is free at the point of delivery (Conservatives, 2010). GPs themselves have also expressed their concerns and do not support the Bill in its current form at all (Rimmer, 2012), which suggests that some professionals simply do not want more power over services, and GPs especially already have a high work load with many patients to see. If GPs were unable to find the extra time to commit to the consortia than it is suggested that these commissioning powers may also be contracted out to private companies, as they, as mentioned have the resources to provide such services, which will then have the power to decide which services are funded by the NHS (Asthana, 2011).
These are just a sample of the various literature available which suggest a deep worry in the future of the NHS, and if the assumptions regarding the inevitable domination of the private sector within healthcare is accepted, it would be fair to say that these policies do suggest a significant move towards a privatised healthcare system. One trade union leader has commented that “…the reforms will result in the NHS becoming ‘nothing more than a brand…displayed outside increasingly privately run and owned hospitals…”(Prentis, 2010). These concerns also leave one to wonder just how much power and choice patients will have over their healthcare if private companies monopolise the system, or simply out price patients that are from more socio-economically deprived areas.
Rather than a more compassionate form of conservatism, these reforms when analysed more deeply may actually represent a continuation of the neo-liberal conservative approach to policy, rather than a fundamental shift. After all, both the outsourcing of services and the introduction of market forces were implemented by the Thatcher-led Conservative Government during its second term in office and as discussed throughout this chapter, the Coalition plans to extend the marketisation process of the NHS further. Performance indicators were also introduced during this period as a way of measuring quality and performance rates, which the Coalition government also intends to continue with the creation of ‘HealthWatch’ to enable patients to view information regarding providers of services and to rate their own experiences (Asthana, 2011).
Further evidence similarly suggests a continuation of Thatcherite health policy rather than a fundamental shift. In the 1980s, for example, the Conservative think-tank Centre for Policy Studies set out proposals to increase private health provision within the NHS whilst attacking the administrative functions within the system. These lines of thought closely resemble current proposals in the Health and Social Care Bill. Interestingly, two key Conservative figures – Oliver Letwin and John Redwood – have consistently backed these moves throughout both periods of Conservative Government (Reynolds et al, 2012). This may explain where the current policy came from as, in its full form; it is not stated within either the Conservative or the Liberal Democrat manifestos. The policy implemented under Thatcher, however, seems rather minor compared to what the Cameron-led government are attempting and therefore does in some ways signify a fundamental shift in the Conservative approach to policy. This shift however may not be in the compassionate direction as first perceived, but may be a more radicalised attempt to retrench the liberal conservative principles of market freedom and to create a small state, rather than a Big Society, as even Thatcher was wary about reforming the NHS due to the status in society it has.
Until the final version of the Bill is clear and has been implemented it is difficult to fully assess whether it represents a clear fundamental shift in the Conservative approach to social policy. On the one hand it aims to empower patients and professionals and does create the opportunity for voluntary organisations to provide services tailored to local communities which does suggest a compassionate form of conservatism as embodied in the Big Society agenda. On the other hand, whilst compassionate intentions may genuinely be driving policy, many argue that private providers will in practice out-compete voluntary organisations in bidding to deliver services. As with the Work Programme, there are fears that the Big Society agenda will amount to little more than privatisation in healthcare; and, given the Conservatives’ historic preference for private healthcare, this consequence – whether unintended or otherwise – may indeed be greatly welcomed by some within the Party.