An accountant’s charter

In January the government published its White Paper Working for Patients which put forward its plan for reforming the National Health Service. The leaks and rumours of the previous year were shown to be substantially correct and the government spent £1m on presenting its controversial proposals in an attempt to allay public fears, gain acceptance for the changes, and lessen the hostility which the majority of doctors and nurses had expressed.


Although the Health Secretary, Kenneth Clarke, has claimed that the White Paper puts patients’ interests first it reads more like an accountants charter, with its emphasis on management restructuring and financial arrangements. The White Paper aims to provide a greater collaboration between the NHS and private medicine, with tax relief on private medical insurance for the over-60s and extensions of competitive tendering which would put more services in addition to laundering, portering and catering in the hands of private firms. There would also be leasing of hospital facilities for commercial ventures such as shops and advertising.


Cheltenham Health Authority has anticipated this trend and spent £15,000 persuading firms to support hospitals in the area in return for publicity such as wards being named after them. The district general manager, Jim Hammond, has not ruled out the possibility of nurses advertising companies on their uniforms, although existing rules may prevent this from happening (Nursing Times 10 May. 1989).


Opting Out
The Health Secretary will have wide powers of appointment on the new NHS policy board and this will extend right down to the general managers of large hospitals, ensuring that pressure can be applied, if necessary, to carry out the government’s policies. The government hopes to see the majority of Britain’s acute hospitals opting for self-government, with the establishment of NHS hospital trusts which would allow these hospitals to set their own rates of pay and conditions of service for staff and. within limits, to borrow money.


The government knows that if rates of pay are negotiated separately in each hospital it will be difficult for the trade unions to operate effectively. At the independent hospital of St. John of God, Richmond, for example, nursing staff are faced with pay cuts of up to £3,000 a year. A skill shortage has been forecast for the 1990s, and with hospitals competing against one another this strategy could rebound if pay rates are increased in some areas to attract skilled staff, causing pay rates to spiral upwards instead of being reduced.
It is significant that the larger acute hospitals should be encouraged to opt for self-governing status as these have the greatest potential for making a profit in private medical schemes. Long-stay hospitals for the elderly, which have a relatively poor profit potential, have not been included at this stage.


Hospital trusts, formed by the hospitals opting for self-government, will remain within the NHS but will be easier to privatise in the future, in much the same way as shares were introduced into the Trustees Savings Bank. Fifty such hospitals have been chosen to receive computers to monitor patient care systems, making it easier to calculate the costs of individual patient care.


Although Kenneth Clarke has stated that the self-governing hospitals will need consultants’ co-operation to be involved in management, and that the applications seeking self-governing status are voluntary, he has pledged tough action against consultants who oppose his “reforms”. It would seem that the only freedom of choice on offer is the freedom to accept the government’s changes.


Two-tier System
Some of the changes in Working for Patients are unobjectionable. It is proposed that appointment times be reliable and that out-patient clinics have quiet and pleasant waiting areas. But these improvements are due to the fact that the present chaotic conditions in most out-patient clinics cause 3.5 million working days to be lost by people waiting for appointments in NHS hospitals and, therefore, it makes good economic sense to improve the system. Patients are to be given rapid notification of the results of diagnostic tests, clear information and sensitive explanations of what is happening to them. These changes are long overdue improvements in current practice, but there is nothing in the White Paper to solve the staffing shortage in pathology laboratories which causes delays, or the long hours and stressful conditions endured by junior doctors which can sometimes lead to a lack of sensitivity in dealing with patients. These reforms may be no more than platitudes to make the White Paper more acceptable to the general public.


The development of a range of optional extras such as single rooms, television and a choice of meals for those who wish to pay for them will create a two-tier system with basic amenities being provided for the poor and better services being provided for the wealthy. In addition, the improvements to hospital facilities will make future privatisation a more attractive proposition for investors.


All of this is in keeping with capitalism’s aim of keeping state provision to a minimum because a centrally-funded health service represents a cost against production. The wealthy are able to avoid the hardship caused by the lack of an adequate health service by purchasing private care. The burden of ill-health and caring for dependent relatives falls upon the working class, who are unable to accumulate enough from their wages to afford expensive hospital treatment.


The provision of 100 new consultants’ posts in acute specialities will help to reduce waiting lists for hospital treatment but has been added to the White Paper as an afterthought and is clearly designed to “buy off” the junior doctors, who will have a slightly better chance of gaining promotion. Doctors have become increasingly militant over the hours that they work. The average weekly hours worked by junior doctors in the UK is 83 compared with 72 hours in Austria and West Germany and 48 hours in Portugal and Italy, according to the British Medical Association. It is estimated that 140 deaths a year are related to doctor fatigue in surgery alone (Which? Way to Health, April, 1988.)


The exploitation of junior doctors has been increased as a result of the 1987 circular issued by the Department of Health which required health authorities to cut the amount of money spent on locum cover to replace doctors who were sick or on holiday. It is claimed that the new posts will reduce the hours worked by junior doctors but consultants tend to create work for their staff not lessen it.


But it is not just junior doctors who are threatened: some managers have been told that their future is at stake if they do not express an interest in self-government, claims Jimmy Johnson, a consultant surgeon at Halton hospital, Cheshire [The Independent, 16 June, 1989).


Internal Market
The White Paper will raise the proportion of pay which general practitioners earn from the number of patients that they have on their lists from 46 per cent to at least 60 per cent. This will force doctors to have larger practices if they do not wish to see their incomes decline. It will also make them less willing to take elderly patients who require a lot of attention, preferring larger numbers of younger patients who are less likely to be ill. There will also be reserve powers to allow the Department of Health to control the number of doctors in contract with the NHS, which could force some doctors to take up private practice or become unemployed.


From April 1991 large general practices of at least 11,000 patients will be able to hold their own budgets with which they can acquire hospital treatment for their patients. They will be able to improve their practices with the money they save on treatments, a temptation to avoid referring patients for more expensive forms of medical or surgical intervention.


Prescription costs will be reduced by the imposition of financial penalties for doctors who over-prescribe. While it may be beneficial to reduce the amount of drugs used, there is a risk that this heavy-handed approach will encourage doctors to prescribe cheaper alternatives rather than the best medicines available.


The most controversial change is the setting up of an internal market which will allow health authorities to buy care from each other. It will permit hospitals with expertise in particular fields, such as hip replacements or heart transplants, to sell their services to both NHS and private hospitals to earn revenue. Despite the government’s protestations to the contrary, this is a backdoor method of introducing privatisation. There is also the risk that hospitals will concentrate on the services that can earn them money to the detriment of less profitable branches of medicine like the care of the mentally ill, the mentally handicapped and the elderly. High-cost treatments, except for private patients able to pay large fees, will become unviable and this will accelerate the creation of a two-tier system of care.


As expected, the White Paper contributes nothing towards preventative medicine, but this is only to be expected as the state functions to protect and facilitate capitalism, which makes profits by selling goods and services to those who can afford them; there is no profit if they are not needed in the first place. The deprivation of the wage and salary working class which is inherent in capitalism is the main cause of ill-health. While capitalism lasts health care, whether state-funded or private, reformed or otherwise, cannot cure society’s ills.


Carl Pinel