Last week, the British Government’s Health and Social Care Bill finally completed what has been one of the most tortuous passages through Parliament of any piece of legislation in recent memory.
The bill has been the subject of 15 months of intense political wrangling and more than a thousand amendments – many focused on its provisions for greater competition in the National Health Service (NHS).
Competition is a fact of life in most areas of UK society, but as soon as it is proposed within the sphere of the state-funded NHS, many people here start to get very jittery about it.
The key concern among critics is that competition between multiple providers will fragment the NHS and remove one of its big potential advantages – its ability to get different elements of healthcare working together within a single, integrated system.
On the other hand, proponents of competition argue that state monopolies like the NHS can become sluggish and unproductive, and that an injection of competition is just what is needed to drive efficiency and push up quality.
When British Prime Minister David Cameron defended his reforms of the National Health Service against a series of aggressive attacks from critics this week, he fell back on a familiar argument – that his reforms would hand control from bureaucrats to clinicians. But the reforms don’t, in fact, hand power to clinicians generally – they hand responsibility for commissioning in the NHS largely to general practitioners (GPs), our answer to US family practitioners. I think it’s worth spending a bit of time explaining quite why, because as other bloggers have written on this site, US policy experts often find it surprising that in the UK such a high status is afforded to family medicine.
GPs in the UK often earn more than their specialist colleagues, and they do so because they have a much more central and wide-ranging role in the British NHS than family practitioners do in the American healthcare system. GPs are in traditional terms, the gatekeepers, and in updated terms, the navigators for the NHS. Patients can’t simply book themselves in to see a hospital doctor – the great majority of first contacts with the health system are with the GP practice. GPs are highly trained, following their medical degrees with two foundation years and then three years of specific GP training (with pressure to extend that to four or even five years).
Although they’re generalists, the profession is regarded as a specialism – and its expertise is measured partly by its ability to manage as many patients as possible in primary care, without the need for referral to hospital. GP care has proved highly cost-effective, both by controlling the numbers of patients who access expensive hospital treatment, and by directing patients to the most appropriate part of the NHS when they do need specialist attention. And in an NHS facing unprecedented cost pressures, that’s given them an enormous amount of power, and is about to gain them a whole load more.
British Prime Minister David Cameron is a man who likes to get his PR right.
In the summer, he used all his experience as a former head of corporate communications at Carlton TV to steer a path through the anger and acrimony generated by his reforms to the National Health Service (NHS).
He whisked up a listening exercise and an independent report, spoke some conciliatory words, and persuaded first MPs and then the House of Lords to wave through his Health and Social Care Bill to its current position on the brink of becoming law.
But just as the debate over the NHS appeared to be calming down, it has been abruptly reignited by a leaked policy document critics of the reforms describe as a ‘smoking gun’, demonstrating the Government’s intention to dismantle the state health system.
The document doesn’t sound a great deal. It is called ‘Developing commissioning support: towards service excellence’.
But its contents are explosive enough that the British Medical Association, which until now had been prevaricating over its response to the Government’s bill, has come down on the side all all-out opposition, with a series of attack ads planned soon.