Dr Gabriel Scally, 58, is the former Regional Director of Public Health for the South-West of England. In March 2012 he left the Department of Health after becoming disillusioned with planned changes to the NHS. He is now Professor of Public Health and Planning at the University of the West of England and an associate fellow at the Institute for Public Policy Research thinktank. He lives in Bristol with his family.
What exactly is happening to our NHS?
The first thing to say is that there is no way to make this simple, but I will try! The recent Bill that set out all the changes in the NHS is around four times the size of the one that originally set up the National Health Service in the first place, back in1948. It’s unbelievably complex, which is part of the problem. The golden rule in trying to understand all this is ‘follow the gold’ and look to see who benefits.
Which bill are you referring to?
The Health and Social Care Bill 2010-12, which was passed (after much controversy and debate) and is now an Act of Parliament which will be implemented on April 1st this year.
What is the overall purpose of the Act?
Well, that’s a matter of political opinion. The Coalition would say it is designed to promote patient choice and reduce NHS administration costs.I see it as an attempt to fragment and ultimately demolish the NHS and I think the current climate of financial austerity is being used to pursue a longer-term agenda aimed at dismantling the state. The private sector is taking over provision of NHS services and there’s a steady rolling out of a programme of active privatisation across the country.
Why did you resign from the Department of Health?
I couldn’t ethically continue to work as a senior civil servant in the DH and be paid to take part in the demolition of the NHS and the public health system. Remember, this government coalition came into power on the back of a promise of ‘no-more top-down reorganisations’, which pleased me because I had been reorganised seven times already. But not only did this turn out to be false, but also this latest restructuring was unlike any of the previous ones because very few, if any, people could explain to you coherently how the system would work. In the past we could always believe that what we were doing was going to deliver a better NHS and better health for the population. On this occasion it’s not possible for anyone to believe that can be true. I just can’t see how the NHS is going to work – and what’s worrying is perhaps that’s the point, it’s not meant to work.
I resigned because I am very alarmed about what’s going on and I wanted the freedom to oppose it (DH contracts mean that whilst working for the department, employees are forbidden from discussing the proposed changes).
So what is the first change we need to know about?
At the moment the NHS is organized into Primary Care Trusts and Strategic Health Authorities. Both of these have been abolished and will disappear at the end of March. From then on there will be one national body – the NHS Commissioning Board. Under that, the NHS will effectively be split into and run by two bodies; Clinical Commissioning Groups and local offices of the Commissioning Board.
What we will also see is the Secretary of State for Health saying that he is not responsible for anything that goes wrong and that it is the responsibility of the NHS Commissioning Board to sort out problems. This in effect means that the NHS is under the control of an unelected, undemocratic body and that there is no effective control through Parliament.
Isn’t getting rid of NHS bureaucracy a good thing?
There’s a lot going on here. On the one hand you have a huge amount of responsibility being handed to the local level, at the same time as their budgets are being cut in real terms. You can’t run the NHS with a smaller civil service in London and a huge number of local authorities all pulling in different directions. Once Clinical Commissioning Groups assume control in April, there will inevitably be issues of so-called postcode lotteries. It’s a recipe for disaster. When there were local Health Authorities and, later, Primary Care Trusts, they met in public, consisted of local people and the public knew that they were concentrating on healthcare for the local population.
What is a Clinical Commissioning Group?
A CCG is a group of GPs who will be responsible for commissioning nearly all the services that you need in the NHS. Most of the money - around four out of every five pounds spent on the NHS - will now go to GPs to commission services, i.e. all the sorts of things GPs would refer you to, whether gynaecology, cancer, paediatrics or whatever, plus community services too, like physiotherapy and district nursing etc.
What’s the thinking behind this switch to GP-led commissioning?
The idea is that GPs are very well placed, as front line doctors, to know exactly what it is that patients want, and they’ll now be in charge of the spending of resources and thereby able to give patients in their area what they need.
Why do you consider this a problem?
The majority of GPs don’t want to take over control of the NHS and its funding - and that’s the express view of their leadership, both in the BMA and the Royal College of Practitioners. I trained in general practice and it was no part of my training to be responsible for millions of pounds of NHS money. GPs are justifiably concerned about the extra work and burden being laid upon them. Also, they feel very uncomfortable with the issue of holding a budget for hospital care being introduced into the consultation between the GP and patient. A patient would like their GP to be ‘on their side’, to be acting always in their interests – but if GPs are responsible for the budget and spending the money, how is the patient going to know what’s got priority in the GPs mind?
You’ve talked about privatisation – how exactly is this happening?
It’s right across the board. The NHS is being atomised into thousands of different, private providers of health services. More and more general practices are being taken over by the private sector, as are some out-of-hours doctors’ services. If you need to go to hospital you may well find the hospital run by a private sector company, providing all of the services you’d expect to be provided by the NHS and making profits out of that which go to shareholders abroad - Hinchingbrooke hospital in Cambridgeshire, which is run by a private sector company called Circle, is an example. And again, there is the issue here about the motivation of the organisation and what lies behind clinical decision making: is it about what’s in the best interest of the patient or is it about making a profit? The absence of a profit motive in the NHS is crucial – it’s an important reassurance to the patients.
Hasn’t the NHS always made use of the private sector?
Yes, when waiting lists got too long, or there was a shortage of capacity. I don’t particularly have an issue with that, as long as the principle remains that the NHS remains in charge of it all. What we are seeing now is the wholesale shift of large parts of the system to the private sector. So it won’t be the NHS occasionally using the private sector as a tool to assist it, it will be the private sector taking over NHS facilities and services. It used to be up to local NHS bodies to decide if the private sector would be invited to tender to provide particular services and that the NHS was the preferred provider. But the new doctrine of ‘Any Qualified Provider’ (AQPs) in effect means that all services will be up for grabs. And grabbed they will be by the private companies.
Other than profit-motivation, what else concerns you about privatisation of services?
There are issues about the quality of care - we’ve seen that in Bristol with Winterbourne View, where the private sector (in this case a company called Castlebeck) stepped in to provide services and provided them extraordinarily badly. And the follow up work done after that scandal showed that two thirds of the private sector facilities weren’t meeting basic standards. There are also issues around transparency. These companies are basically not accountable to anyone, other than their shareholders.
So who is accountable when things go wrong?
This is what worries me. NHS organisations in the past were all, without exception, accountable ultimately to the Secretary of State. Private sector organisations are not. This is a big, important difference.
There is, of course, the Care Quality Commission (CQC), which is charged with overseeing standards of care and carrying out inspections, and also there is an organisation being established called Healthwatch. I think they will both have an enormous task. CQC fell down badly in respect of Winterbourne, and because of the privatisation of so many services there’s going to be a much more complex landscape within which they are going to have to work. I think it will be very difficult for them.
Can the NHS as we know it be ‘saved’?
The NHS was creatable in the first instance so it is possible to recreate it, but the longer it goes on and the more radical the changes are, the more difficult it will be to put it back together again. I haven’t left the field – I’m still very actively involved in trying to ensure that the NHS isn’t damaged and also that when there is an opportunity to restore it, we can put it back together again in a way that will leave it stronger and better than it ever has been before. That’s why it’s important to oppose the changes over the next two years and support NHS staff and campaign groups who are against privatisation. Make sure your local councillors and MP very clearly understand your views, and in the run up to the next general election, help and support those who are standing on a platform of reversing these changes and giving us back our NHS.
Interview: Fiona McClymont, photo: Jo Halliday
First published issue 72, Feb 2013