Phil Bevin begins his article as follows:

“The NHS, once a single organisation that provided comprehensive healthcare free to all, at the point of need, is dead, and the Labour Party is an accomplice to its murder.”

The Kings Fund says that in England “there were an estimated 570 million patient contacts with GP, community, mental health, hospital, NHS 111 and ambulance services in 2021/22″.  This is equivalent to every person in England being assessed, treated and cared for by the NHS 10 times a year on average, or 1.6 million interactions with patients every day.

It is an unhelpful exaggeration to say that an organisation that provides mostly satisfactory health care on this scale continuously is dead. That is not to deny that NHS England has problems.  It has serious problems, particularly in meeting the demand for its services.

Furthermore, the NHS has never been a single organisation, for example, from the start, primary care was provided by an army of private general practitioners.  That private element of the NHS persists to this day but there is no mention of it in Phil Bevin’s article.  Also, the NHS was completely free to all for only a few years before charges were introduced.

Health care denial

The main message from Phil Bevin’s article is that NHS England is dead.  Another message is that NHS England is legally entitled to deny care to patients who need it.  It says that NHS England is now “a fragmented system that encourages the denial of healthcare by design to the benefit of the private health insurance industry”.  It goes on:

“Underpinning this shift from comprehensive care provision to incentivising care denial are changes to the law. The legalisation of care denial was concluded with the Health and Care Act 2022, which removed the obligation for Integrated Care Systems to treat patients seeking care via Accident and Emergency Wards.”

The message from Phil Bevin is: don’t be surprised if the next time you turn up at A&E, you are turned away and, if you object, you are told that it is legal under the Health and Social Care Act 2022.  This is nonsense, isn’t it?  If people were being denied treatment in anything other than the most exceptional circumstances we would know about it and questions would be asked in the House of Commons.  Some treatments are denied, like homeopathy, which used to be provided, but that is not ‘denial of treatment’ in general.

Health and Social Care Act 2012

This Act was the brain child of Andrew Langsley who became Health Secretary in the coalition government formed in June 2010.  His plan, developed during several years as shadow Health Secretary, was to establish a comprehensive system of competitive tendering for health care provision in NHS England, a system which would be mandatory in most instances and open to any qualified provider within or outside the NHS.  The Act put private health care providers on a par with NHS providers in the operation of NHS England.  The Act also made major changes to the structure of NHS England, in particular, it created GP-led clinical commissioning groups (CCGs) to organise services in local areas.

With this Act the process of marketisation in NHS England reached its zenith.  This process began with Kenneth Clarke’s White Paper Working for Patients in January 1989, a set of changes that introduced a purchaser/provider split in the NHS and came into effect in 1991.  Famously, Kenneth Clarke said that as a result of these changes he wouldn’t have to close hospitals in future, since the market would take care of it from then on.  Under New Labour, the system for purchasing services was amended more than once and more services were bought from private providers.

The Cameron government had difficulty getting the 2012 Act through Parliament.  This reflected doubts within the NHS about the workability of the Act in practice and fears that private provision would be vastly increased.  But it was eventually passed into law in March 2012 after an unprecedented pause in the legislative process and extensive amendments.  By then, the Act’s author, Andrew Lansley, had become immensely unpopular and he was sacked in September 2012 and replaced by Jeremy Hunt.  A year later, Simon Stevens was appointed Chief Executive of NHS England.

Quoting Dr Bob Gill, PHIL BEVIN writes the following about the Health and Social Care Act 2012:

“The 2012 Health and Social Care Act converted the NHS internal market into a fully compulsory external market with all services up for grabs by the private sector.“

Phil Bevin’s article implies that this system envisaged in the 2012 Act continues to operate today.  

I think there is considerable doubt that it is the case.  Indeed, it may be the case that competitive tendering no longer operates in NHS England at all:  for example, of the NHS Long Term Plan published in January 2019 Wikipedia says:

“The plan marked the official abandonment of the policy of competition in the English NHS, which was established by the Health and Social Care Act 2012.”

However, I have been unable to find solid documentary (non-Wikipedia) proof that the competitive tendering provisions of the 2012 Act have been abandoned.  However, below are some indications that it might be so:-

(A) The NHS under the coalition government (King’s Fund, February 2015, see here)

In this review of the record of NHS England in the three years after the 2012 Act was passed, the King’s Fund wrote:

“The 2010–15 parliament has been a parliament of two halves for the NHS. The first half was dominated by debate on the Health and Social Care Bill (which was largely designed to devolve decision-making, put GPs in control of commissioning, and extend competition and choice). The second half was taken up with limiting the damage caused by the Bill, with less emphasis on competition and greater efforts to strengthen the regulation and quality of care and prioritise patient safety.”

“Jeremy Hunt (Lansley’s successor) has taken the lead on damage limitation, studiously ignoring many of the reforms promoted by his predecessor (rarely mentioning competition, for example) and staking his claim as the defender of patients’ interests in the wake of the Francis report into failures of care at Mid-Staffordshire NHS Foundation Trust.”

“Debate on Lansley’s plans generated strong feelings on all sides, with critics claiming that the Health and Social Care Act 2012 would not only extend competition but also lead to much greater privatisation of provision. In fact, our assessment shows that the private provision of care to NHS patients has changed little with over 90 per cent of services still delivered by NHS providers.”

(B) Five Year Forward View (published by NHS England, October 2014, see here)

This document, prepared under the leadership of Simon Stevens a couple of years after the 2012 Act was passed, doesn’t mention the Act at all and the word “competition” doesn’t appear in it.

(C) Jeremy Hunt (Interview with Health Service Journal, 28 November 2017, see here, behind paywall)

“The idea of lots of competing foundation trusts and payment by results works well when you have in your mind that most of the work the NHS does will be single episode elective care, but when you’re dealing with complex patients who are going in and out of the system a lot those structures prove not to be fit for purpose. … The NHS internal market and the independence of foundation trusts are hampering efforts to deliver standardised safe care …” 

(D) The NHS long-term plan explained (King’s Fund, 23 January 2019, see here)

“On 7 January, the NHS long-term plan (formerly known as the 10-year plan) was published setting out key ambitions for the service over the next 10 years. … It signals a shift in gear from the bottom-up, iterative approach that followed the Forward View, while retaining a balance between national prescription and local autonomy. However, there is now no doubt that the NHS is moving rapidly away from the focus on organisational autonomy and competition that characterised the Lansley reforms.”

(E) Are Andrew Lansley’s NHS reforms being binned? (BBC, 19 January 2019, see here)

“Consider this, it is just over three years since the last piece of the jigsaw in Andrew Lansley’s controversial NHS reforms was put into place.  In 2015, health visitors moved into local government to complete the transfer of public health from the NHS to councils.  It completed what former NHS chief executive Sir David Nicholson once described as a reform programme so big it could be seen from space.

“Now – with the country mired in Brexit – it is easy to forget just how tricky it got for the government in the early coalition years.  Unions and royal colleges lined up to oppose the changes and at one point it even threatened to turn the coalition partners against each other.  Eventually changes were made and Mr Lansley got them over the line with the Health and Social Care Act passed in 2012. 

“The restructuring created a new body, NHS England, to run the health service, set up new regulators and replace primary care trusts with GP-led clinical commissioning groups (CCGs) to organise local services, while handing healthy lifestyle programmes to town halls.  Underpinning the changes was the idea that greater competition in the NHS would help create a service fit for the 21st Century.

“But on Monday that was effectively reversed, with the NHS Long Term Plan arguing collaboration was key.”

How much does the NHS spend on the private sector?

Kings Fund: Is the NHS being privatised? (1 March 2021, see here)

“It is difficult to determine how much the NHS spends each year on the private sector. This is because central bodies do not hold detailed information on individual contracts with service providers, especially where these contracts may cover small amounts of activity and spending. Information on private sector spending is available from the annual accounts of the Department of Health and Social Care but also requires judgement and interpretation.

“In 2019/20 NHS commissioners spent £9.7 billion on services delivered by the private sector (also called ‘independent sector providers’). This is more than the £9.2 billion spent in 2018/19, but due to inflation and growth in the Department of Health and Social Care budget, the share of their total revenue budget that was spent on private providers remained relatively stable at 7.2 per cent.

“The Department of Health and Social Care accounts also record how much the NHS spends on services provided by the voluntary and not-for-profit sectors and local authorities. If spending on these services was added to the spending on independent sector providers, this would total £14.4 billion in 2019/20. This amount was 10.8 per cent of total revenue spending by the Department and is similar to the levels in previous years.

“The Department of Health and Social Care’s accounts also show that NHS providers spent £1.5 billion on services from non-NHS organisations in 2019/20. Data from NHS Improvement shows that NHS providers spent £271 million on outsourcing services to other providers, including the private sector, in 2018/19 – up from £221 million in 2017/18. This includes outsourcing elective hospital treatment in order to deliver waiting times targets.

“If spending on primary care services – including GPs, pharmacy, optical and dental services – is included, some have estimated that approximately 25 per cent of NHS spending goes on the private sector. ….

“Private provision of health care services has always been controversial, even though some services, such as dentistry, optical care and pharmacy, have been provided by the private sector for decades and most GP practices are private partnerships.”

NHS England: what needs to be done?

NHS England has hundreds of millions of patient contacts annually and provides satisfactory health care for millions of people, which is largely free at the point of delivery.  But its service also has serious deficiencies – too many people get a less than satisfactory service, in too many cases waiting time for treatment is too long, etc, etc.  These problems need to be addressed now.

A necessary condition for doing so is that the NHS fills the existing gaps in its medical workforce and pays its medical staff sufficient to retain them.  That cannot be done overnight but it can be done eventually, if the Government provides the appropriate training places for relevant staff and sufficient extra funding.  This would increase hospital throughput and help to lower waiting times.

Hospital throughput could also be increased if the perennial problem of stranded patients was fixed: according to the Guardian, last October on average one in seven NHS England hospital beds were occupied by patients who are well enough to be discharged but, because of the long-standing inadequacy of our social care system, did not have suitable places to go.  That has to be addressed.  Social care staff wages need to be increased so that more social care staff can be recruited, trained and retained – and the Government will have to provide sufficient extra funding.

Phil Bevin has absolutely nothing to say about how these deficiencies in health care provision can be addressed.  Despite the fact that the NHS provides satisfactory health care to millions of people, he says that it is “already dead” and that “the only solution now is not rescue but rebirth”.  Extra cash is not the answer, he implies: “the notion that money is the main issue” is “entirely false”, he writes.  The answer is “a new NHS, founded on the original principle of healthcare as a human right, free to all at the point of need”.

But at its birth any “new NHS” will be faced with the same deficiencies as the old NHS, with the same inadequate staff and infrastructure as the old NHS.

David Morrison

27 September 2023