Dr No has no doubt that the most devastating blow to be wrought by the Tories on the National Health Service in their Health and Social Care Bill is the abolition of the Secretary of State’s duty to provide a comprehensive health service. At a stroke, it removes ministerial responsibility and accountability, and so renders the NHS as an army without a chief, a supertanker with no one on the bridge, a body without a head. And when mayhem arrives, as it surely must, when the troops run wild, or the tanker strays off course, there will be no one in charge, no one on whose door we can knock, and demand redress. So long as the Secretary of State has ‘acted with a view’, an invidious wording blessed with the legal slipperiness of a bar of soap, he can profess to have done his duty, and declare, even as the tanker hits the rocks: ‘not my problem’.
Decapitation is of course a brutish but undeniably effective way of killing off the comprehensive national health service, but what about the other central tenet of the (N)HS, that it is free at the point of delivery? The Tories, naturally enough, make loud claims that this sacred cow of Modern Britain shall never be slaughtered, and indeed the Bill appears to support this. Or does it? Once again, scrutiny of past versions of the Act, and the wording proposed in the new Bill, reveals a subtle change. Where previous versions had ‘The services so provided shall/must be free of charge…’, the phrase ‘so provided’ linking the absence of charge to the comprehensive health service provided by the minister, we now have ‘The services provided as part of the health service in England must be free of charge…’
On the face of it, this apparently minimal change might appear a necessary uncoupling, given that the Bill removes the duty of the minister to ‘so provide’ a comprehensive national health service. But it also does something else. It defines a subset of services provided, that subset provided as part of the health service, and so there are some that are not provided as part of the health service. If we then add the removal of the duty of the minister to provide a comprehensive health service, we can see that another subset – possibly quite a large subset, given the absence of a duty to provide a comprehensive service, possibly not – of services might now exist: those services not provided as part of the health service.
Now all this might appear pedantic nit-picking by Dr No, but he begs you indulge his fancy for just a moment longer. Whether intentionally – the conspiracy version – or accidentally – the cock-up version – other better known parts of the Bill will transform the our health service into a system that closely mirrors the American health care system – a system, we might add, that costs almost twice as much (16% of GDP compared to our 9%), for worse outcomes (infant mortality/1000 live births is higher, at 6.06, compared to our 4.62 and life expectancy at birth is lower, at 78.37yrs, compared to our 80.05yrs).
Where the Americans have healthcare maintenance organisations (HMOs), often large private corporations, that insure ‘enrollees’ and ‘manage’ their healthcare with providers chosen by the HMO, we shall have large privately run (general practices, remember, are self-employed businesses – the so called independent contractor status) commissioning consortia, all too often enthusiastically assisted by American HMO back-room boys, managing our healthcare delivery by ‘any willing/qualified provider’ chosen, we should note, not by us, but by our commissioning consortia.
As the saying goes, if it walks like a duck… The core feature – HMOs contracting with their choice of provider – of the American system will be in place. And if it walks like a duck and swims like a duck, before too long it might start quacking like a duck. Although consortia will be statutory bodies, and so have statutory functions, given the vacuum created by the removal of the minister’s duty to provide a comprehensive health service, there is no bar that Dr No can discern to the establishment of a parallel insurance based health care system; the once registered NHS patient reborn as an HMO enrollee…as long as they, or their employer, can afford it.
Far-fetched, even preposterous? Dr No thinks not. We already have a dental service run along these lines: glossy private practices funded mostly from insurance, alongside a destitute and creaking NHS funded service – and already that makes use of top-up payments. And then consider what has happened in higher education: once free tuition, now increasingly topped up by fees. The precedents are all too plain to see.
The Health and Social Care Bill, if enacted in its present form, will not only kill of the golden NHS goose, it will also pave the way for an American duck – or does Dr No mean turkey? – of a health care system, a system in which the rich buy frivolous care, while the uninsured poor suffer in destitution and depravity.