|Plans to encourage a private market within England's health sector have sparked protests [Photo: Chris Moffatt]
Shirley Murgraff is an 80-year-old woman from the east end of London. She's had 23 hospital admissions over the past 60 years, yet never had to directly pay for any of them, not even for several expensive treatments for cancer.
But she remembers a time before Britain's National Health Service was born, a time when people who were sick or injured did have to pay upfront for medical care.
"I was born and brought up in Hackney in the 1930s," she told Al Jazeera. "I had lots of childhood illnesses and as far as hospitals were concerned, if you wanted or needed treatment, money was an issue. If you couldn't afford it, you had to go without, and that's what we're going back to now. It's an absolute scandal."
"We've worked for it and paid for it all our lives ... it's not theirs to sell. The NHS is our NHS."
- Shirley Murgraff, NHS patient
She was referring to proposals approved on October 12 by the House of Lords, the second chamber of Britain's parliament. The Health and Social Care Bill set out designs to introduce further competition within the health sector, encouraging private companies to take control of medical care once provided free of charge at point of access, paid for by general taxation.
"We've worked for it and paid for it all our lives," says Shirley. "It's not theirs to sell. The NHS is our NHS."
Britain's government - a sometimes fractious coalition of Conservatives and Liberal Democrats - believes that creating a private marketplace within England's health system (NHS Wales and NHS Scotland are not affected by the changes), in which the NHS is but one of the providers competing for patients' cash, will lead to £20bn of efficiency savings within five years.
Professor Allyson Pollock at Queen Mary, University of London, and a healthcare professional for nearly 30 years, told Al Jazeera: "These are not reforms. This is a bill which will abolish the NHS as we know it."
"These are not reforms. This is a bill which will abolish the NHS as we know it."
- Prof Allyson Pollock
No-one yet knows to what degree private medical corporations will take over, as it will be up to groups of local GPs banding together in "Clinical Commissioning Consortia" which will determine which treatments will be provided free of charge to patients - either by NHS or private providers - and which will require an upfront fee. But the world has changed since Aneurin Bevan founded the NHS to provide care "from cradle to grave" in 1948, an era when heavy government investment rebuilt economies and communities shattered by war. So is a reorganisation and a shift toward a market philosophy now in order?
Shirley admits that there is room for improvement within the NHS. "Not every experience was absolutely marvellous, but having had ten lots of major surgery and now being near 81, it seems to me that they must have got something right," she told Al Jazeera.
"We're already in a situation where there are people who can't afford their prescriptions, and I know there are people who can't afford to go to their dentist.
"It's just, to me, not what a civilised society ought to be about."
Not everyone agrees, naturally. Tom Clougherty, executive director of the free market-focused think tank The Adam Smith Institute, believes the proposed reforms don't go far enough and, in fact, "the government shouldn't be in the business of providing healthcare".
"The government shouldn't be in the business of providing healthcare. It should all be privately owned and privately operated ... where the funding is guaranteed by the government"
- Tom Clougherty, Adam Smith Institute
"It should all be privately owned and privately operated," he told Al Jazeera. "A separate question is where the funding is coming from. It's perfectly possible to operate a system where all of the people involved in delivering healthcare are private operators who are competing with one another and offer the best services at the lowest cost, but where the funding is guaranteed by the government."
Former cancer patient Shirley is horrified by the idea. "I think it's obscene that shareholders will be sitting there doing nothing and making a profit from other people's suffering, ill health and distress," she said.
"A private company's first obligation is to its shareholders, so, by any measure, the patient cannot come first."
Mr Clougherty, of the think tank credited with being "the intellectual force behind the privatisation of the Thatcher era", disagrees this would simply be "good news for shareholders".
"The government should simply operate as an insurer and pay some kind of standard tariff for operations - you wouldn't have patients staying at the Ritz hotel for a month and have any operation under the sun [at taxpayer expense]."
And as for the morality of profiting from providing medical treatment? "People think 'oh no, people shouldn't make money out of healthcare' - but people make a lot of money out of food, and that's something we could hardly do without. And the profit motive in food has led to places like Tesco offering a huge variety of food of a high quality at a low price, that's what you do want in healthcare."
However, Mr Clougherty says there is nothing within the proposals - now sent for the Lords' committee discussion - that would be effective in either of the government's goals: to increase competition or to reduce bureaucracy.
"Laws are like sausages - you don't want anyone to see how either are made. This is healthcare reform that has gone all the way through the sausage factory a couple of times."
- Tom Clougherty, Adam Smith Institute
"I'd advise the Lords to throw this bill out and start again," he said.
"Laws are like sausages - you don't want anyone to see how either are made. This is healthcare reform that has gone all the way through the sausage factory a couple of times and it's come out practically amounting to nothing.
"This is a policy that wasn't particularly well thought out in the first place, and was then subject to a lot of lobbying from special interest groups in healthcare - such as the NHS and the trade unions."
But surely healthcare policy makers would want to hear from those healthcare professionals who provide the vast majority of healthcare and medical support?
"Up to a point, yes - but I don't think you necessarily want to let them design the healthcare system so it works to their own advantage. This is the main thing that you have to tackle in healthcare, that you don't have a system which is centred around the patient, or the consumer. That's not how any effective business would be run, and I don't think that's an effective way to run a public service either."
High wages for NHS workers have absorbed extra funding given to the NHS in the past decade, he said, "while productivity has declined".
As of February 2011, starting salary for a nurse (with the pre-requisite bachelor's degree in nursing) is £21,000 [$32,800]. The payscale for NHS senior management, however, goes up to around £97,000 [$152,000], excluding bonuses.
"What you want," says Mr Clougherty, "is for the well-functioning parts of the system to grow and flourish, and for the bits that can't be made to function properly to die off. That's how a dynamic system would work and that would be a good thing for improving standards."
A matter of trust
|Protesters urged peers to reject the government's
healthcare proposals [Photo: Ian Parker]
The Department of Health, headed by Conservative MP Andrew Lansley - who in 2010 courted controversy when it was revealed he had accepted a £21,000 ($32,800) donation to his private office from the head of private healthcare provider Care UK - agrees with the institute's assessment that "doctors have got everything they want out of this reform".
A spokesman for the department's "NHS Modernisation Team" told Al Jazeera: "We are not making cuts - the only thing we are cutting is waste. We said we would increase the NHS budget in real terms, and we are.
"The NHS can become more efficient and we want to raise it by £20 billion worth of productivity improvements over the next few years. That is not a cut - because all the savings will be reinvested into frontline patient care."
"The principles of our modernisation plans - patient power, clinical leadership, a focus on results - have been widely supported as reported by the independent NHS Future Forum. And we accepted all of their recommendations to strengthen the bill.
Dr Louise Irvine, a GP partner in Lewisham, south-east London, rejected the notion that the proposals had the support of the healthcare community.
"That is a compete lie. There have been opinion polls which show that around 40 per cent of GPs are against these proposals, compared with just 20 per cent or so of GPs who favour the changes. There is, however, a general feeling that it's inevitable," she told Al Jazeera.
Indeed, in the past week, some 400 public health specialists, doctors and academics wrote to members of the House of Lords, urging them to reject the proposals.
"If we start letting commercial factors come in and influence our decisions, we'll lose our patients' trust"
- Dr Louise Irvine, family GP
"The average GP is worried about the doctor-patient relationship. If we start letting commercial factors come in and influence our decisions, we'll lose our patients' trust," said Dr Irvine.
"For example, people who have a cold don't need antibiotics and at the moment I can say: 'Look, this antibiotic won't help you because you've just got a virus' - but in the future I think they will say: 'Oh you're just trying to save money.' It will undermine that relationship."
Dr Irvine, who has more than 30 years experience as a health professional, and 20 years experience as a family GP, added that there was a "conflict of interest" arising.
"There's a minority of GPs who are quite powerful and influential, who are in favour of these reforms, and many of them have set up private companies that provide services.
"In York, there was a practice that wrote to all its patients, saying that, as there were going to be certain procedures which were no longer going to be offered on the NHS - removing minor lumps and bumps - 'here are four private providers, including your own GP practice, who will perform the operation for a fee'.
"There's a minority of GPs who are quite powerful and influential, who are in favour of these reforms, and many of them have set up private companies that provide services"
- Dr Louise Irvine, family GP
"And in Southwark [central London], there's a GP practice which provides specialist Ear, Nose and Throat consultations, and their doctors have been told they should refer patients to that [private] service and not to the local hospital. So the money is then going into the GP practice which should have gone into the hospital.
"This is the beginning of the shape of things to come."
Distinction of duty
What seems to have provoked the most ire is the perception that the changes have been somehow "sneaked through" without the public being drawn into the discussion. In an essay for the London Review of Books, award-winning author James Meek summarised it thus:
|Lansley chose July 19, the day Rupert and James Murdoch had the media transfixed with their testimony to the Culture Select Committee, to let slip that from next April a billion pounds' worth of NHS services, including wheelchair services for children and 'talking therapies' for people suffering from mild depression, anxiety or behavioural awkwardnesses like obsessive compulsive disorder, will be opened up to competitive bids from the private sector. The doctor and Daily Telegraph blogger Max Pemberton described it as 'the day they signed the death warrant for the NHS'.
Throughout the latest debate on the Health Service's future, the Conservatives have praised it as an abstract concept, pledging to uphold 'an NHS that is free at the point of use and available to everyone based on need, not the ability to pay'. But it is quite possible to praise something even as you legislate it out of existence. Changes do not need to be advertised as embodying a cumulative destructive purpose for that purpose to be achieved. The fall of the Roman Empire was never announced, yet its fate was sealed once its rulers, no doubt for reasons of efficiency, introduced a choice of competing barbarians to defend its borders.
A legal team commissioned by campaign group 38 degrees conducted a two-month study of the proposals and concluded: "The bill will remove the duty of the Secretary of State to provide or secure the provision of health services which has been a common and critical feature of all previous NHS legislation since 1946."
This was immediately denied by Health Secretary Andrew Lansley.
"We fundamentally disagree that the bill would dilute the government's responsibilities with regard to the NHS. The Secretary of State will continue to be responsible - as now - for promoting a comprehensive health service," said a spokesman.
But that's not enough for Dr Irvine.
"The change in wording [from 'provide' to 'promote'] is a way of saying they no longer have direct responsibility," she says.
And it will be the least profitable cases which will slip through the net, she adds.
"Private companies like things that are predictable in their outcome. If you broke your arm, you can quite accurately predict what that's going to cost in terms of the level of help you'll need. And so then you can plan ahead: 'Ok, we're going to do so many straightforward hernias or hip replacements or whatever.' What you can't predict is the outcome of mental illness, for example, which is so variable - sometimes a great deal of input is needed and sometimes less.
"What happens in the NHS is that a hospital receives funding per item of care, when some patients need less, the hospital can then make a little bit of surplus on that patient. Some patients need more input, so the surplus from the first goes to help subsidise the patient who needs it. But if you have private providers cherry-picking the easiest cases, then you will leave the NHS to deal with the more complex cases - but they won't be paid enough to cover those costs and could become financially destabilising.
"The risk is that NHS hospitals may end up going bankrupt and closing as a result."
|The Conservatives campaigned against NHS cuts in their
2010 election campaign [Photo: ConservativeHome]
Cutting 'waste', increasing paperwork
The department of health said competition would be "a method of driving up the quality of service for patients".
"We will never privatise the NHS, and will create a genuine level playing field to stop private companies 'cherry-picking' profitable NHS business," a spokesman told Al Jazeera.
The government maintains that the cost of the proposal "is only a fraction of the long term savings which come from it". "We are cutting waste and are still on track to reduce administrative spend by a third," said a spokesman.
Dr Irvine remains unconvinced: "That is complete baloney." She pointed to parliament's own health select committee which showed in 2005, that limited market competition introduced since 1990 had pushed up the percentage of the NHS budget spent on administration by nine per cent in 15 years.
"The cost of full marketisation could easily reach 20 to 30 per cent of the national health budget," she said. "In the US, they spend 30 cents in the dollar on administration."
But won't stripping out the Primary Care Trusts and Strategic Health Authorities make for a more efficient system with less red tape? Not so much, says Dr Irvine: "There will even more layers of bureaucracy and management"
"The NHS commissioning board, Monitor and the Care Quality Commission, the Health and Wellbeing boards, the Clinical Commissioning Groups, the NHS Healthcare Commission, the Competition and Cooperation panel, the Office of Fair Trading, Clinical Senates, Clinical Networks, Healthwatch UK - and local healthwatch groups as well."
Deserving a thorough examination
So where does this leave the proposals? More than 100 members of the House of Lords spoke in a marathon debate, but dissenting peers failed to overturn the government's plan, which was approved by a 354-220 vote. Its passing into law is now all but guaranteed, as a small group of lawmakers meet to discuss the minutiae of the bill.
|Campaign group UKUncut has pledged to
keep up pressure on lawmakers [Photo: Ian Parker]
This further consideration is necessary, as many elected lawmakers did not even read the proposals when they were put through the House of Commons, says Professor John Ashton, the director of public health for the county of Cumbria.
"This bill is hundreds of pages long," he told Al Jazeera. "It is very complicated, and when it came to the House of Commons, it was pushed through really rapidly in two days - even though there were 1,000 amendments to it. It was not properly scrutinised."
And not all Lords are willing to give up the fight just yet.
"The NHS came into being in the year I was born. I am not going to do anything to endanger it now," Lord Jones of Cheltenham, a Liberal Democrat peer, told Al Jazeera.
"The bill will run and run for several months in the Lords. Those of us with stamina will stay the course. Now the real work starts of knocking the bill into shape."
Taking part in health activists' occupation of Westminster Bridge, 80-year-old Shirley Murgraff concurred.
"The politicians that are in power are telling lies about what it all means - on a big scale - and others maybe aren't sufficiently interested and therefore aren't representing their constituents properly," she told Al Jazeera.
"They should be listening to their constituents, because what we want is the NHS we know and love, with all its imperfections, which we'll fix - together."
Follow James Brownsell on Twitter: @JamesBrownsell