On opposing the current NHS reorganisation

In this week's HSJ, former Labour advisor and all-round competition evangelist Paul Corrigan hits out at opponents of the government's market-based reforms to the NHS accusing them of defending their own vested interests.  It might be just me, but I think I detect a hint of tetchiness about his comments and the potential for the modifications to the Health and Social Care Bill driven by the NHS Future Forum to undermine the holy grail of competition.  To true believers in the 'Gospel according to St Julian (LeGrand)' like Paul, this is heresy.

Unfortunately, looking at other examples of privatisation and market-based reforms over the last 30 years, there's ample evidence for scepticism about the supposed benefits, and some clear alarm bells about the potential negative consequences of these reforms.  To get a full appreciation of the issues here, you need to consider the two parallel processes that have operated in many of the privatisations that the UK government has undertaken.  On the one hand, you have the transfer of ownership of publically run companies, either through stock market floatation or contract letting processes.  Secondly, there is the creation of complex artificial markets and regulatory frameworks within which these newly privatised firms operate.

The NHS reforms tick both of these boxes to a greater or lesser extent.  Certainly there has been an increasing willingness to contract out more and more NHS services so they are 'delivered' by the private sector under NHS branding.  The coalition government's interest in encouraging NHS organisations to become mutuals, is and arguably more palatable version of the same thing. 

But even before this, the last Labour government were heading down the road of creating an artificial market in which individual NHS organisations competed for business, the idea being that this would tap the supposed benefits of competition and markets (driving down costs, stimulating innovation, driving difficult decisions by reduction to a financial bottom line), with regulation offering protection against the negative elements.

The problem for me is that government has a poor track record in devising these artificial markets, particularly in more complex industries where the twin pitfalls of perverse incentives and unintended consequences beckon.  You only have to look at the debacle of rail privatisation in detail to see the
potential for disaster.  On top of that, government's track record on managing the healthcare sector generally is pretty poor. Part of the attraction of marketisation is the frustration felt by governments in trying to exercise control over a large, complex and unweildy beast like the NHS.  The discipline of the market is a seductive model with its promise to automate some of the messy business of managing the beast whilst also insulating politicians from the consequences of change.

However, in attempting to redesign the systems they need to be mindful of Marios Papadopoulos' analysis of surgical patients using chaos and complexity theory, which if nothing else helps to illustrate the difficulty in predicting the outcomes of specific inputs.  Papadopoulos' characterisation of the NHS as a 'complex system on the edge of chaos' rings so true to many of us with a reasonable amount of NHS experience.

So my response to Paul is that far from being concerned with defending our cosy little fiefdoms, those of us speaking out against the reforms are doing so from the following viewpoint:

1. We are not convinced that the reorganisation of the service will deliver the promised benefits
2. We believe the reorganisation will waste time, money, goodwill and undermine patient care
3. We believe the reorganisation of the service will have significant negative unintended consequence
4. These unintended consequences are likely to include increased (if better hidden) management costs and bureacracy and an undermining of integration and cooperation
5. We believe that the reorganisation will lead to reduced terms and conditions for staff and the fragmentation of the NHS as an employing organisation and
6. that this will have a detrimental effect on service delivery in the longer term.
7. We are not convinced that the reorganisation will allow ministers to distance themselves from their responsibilities for the NHS
8. We believe the reorganisation will lead to an increase in costs and an overall decline in value for money for the public as an more money is siphoned out of the system for private profit