It is fair to say that Snatcher Thatcher was and for many still is the high priestess of marketisation and privatisation, and of choice and competition, and so in the interests of brevity, Dr No will call the commissioning measures contained within the Health and Social Care Bill Snatcher Commissioning. Such a name also has the utility of high-lighting what will be one of the defining characteristics of the bill’s reforms, should they come to pass: hundreds if not thousands of private concerns all competing to snatch their share of the commissioning cake.
It is also fair to say that a bill running to hundreds of pages, and an amending bill at that, now further burdened by hundreds of amendments to the amendments, lacks clarity. It may even be that it is so complicated that it lacks internal coherence; Dr No cannot be sure, because he has yet to master the feat of holding hundreds of amendments, further amended by other amendments, in his head at one time. Nor is it any surprise, given the weight of complexity, that many, including politicians and health care staff, not to mention the public, have little concept, let alone understanding, of how Snatcher Commissioning will work in practice. And so, in the interests of shining a light into those dark recesses where the sun don’t shine, and the milk of human kindness sure don’t flow, here is Dr No’s back of the (large) envelope guide to how Snatcher Commissioning will work in practice.
The established NHS has at its head a secretary of state, who has a global duty to provide, or secure the provision of, health services. The first, and to many perhaps the most important effect of the bill will be to relieve the secretary of state of this duty. The secretary of state’s role will be severely curtailed, to one of promoting, much as a flag-waver might promote the monarchy, the health service. He or she will have no day to day duty to provide health services, and will instead be reduced to a lonely figure on a distant hill-top, semaphoring messages of promotion. The latest amendment, proposed by Baroness Jay – “The Secretary of State retains ministerial responsibility to Parliament for the provision of the health service in England”, which has been cordially accepted by the government – does indeed restore ‘responsibility…for the provision of the health service’, but crucially, it fails to impose a ‘duty to provide’. The difference is subtle, but important: consider whether you would prefer a duty to pay tax, or a responsibility to HMRC for the payment of tax. The former is qualitatively tighter, more binding.
Under Snatcher Commissioning, overall charge of commissioning will rest with a quango, The National Commissioning Board. The NCB will set direction, decide who can and can’t commission, and hold accountable those further down the commissioning chain; and for rarer and exceptional (and GP) services, it will itself commission services. But, again crucially, the NCB will not be directly accountable to parliament or a minister. The DoH says the NCB will be ‘nationally accountable’ – but the dative is missing; and then adds it will be ‘accountable to the Secretary of State via an annual mandate’, gobbledygook echoed to parliament by NCB Chair Professor Malcolm Grant. The mandate itself is defined in the bill, and amounts to little more than an annual ‘must try harder’ briefing to the NCB from the flag-waver. In practice, the NCB, which has immense powers, will be able to, and no doubt soon will, do pretty much the hell what it wants to do, without any clear line of true accountability.
The vast majority of day-to-day commissioning is meant to be done by Clinical Commissioning Groups (CCGs), the merry bands of brother GPs charged with commissioning their local services. That, at least, is the rhetoric: GPs at the heart of commissioning, ‘the engines of the new system’. But already, it is clear that the reality will be very different. Indeed, Dr No has already characterised this caper as Captain Mainwaring’s Commissioning. Many GPs have neither the heart nor the will, let alone the knowledge and skills, or even time, to undertake this complex task. Even those GPs who have the hots for commissioning are getting cold feet.
The great majority of GPs will instead farm out commissioning to ‘commissioning support services’, the dark hordes of private corporations, many with American links, waiting in the wings for just this to happen. Before we know it, NHS commissioning will be largely in private hands. Private concerns that, if they have their wits about them, will of course also have privately owned provider arms.
Now, of course no one for a moment is suggesting that United Commissioning Services will preferentially award commissioning contracts to United Hospitals – such a suggestion would be as scurrilous as it is scandalous. But what will happen is a radical change in mindset, from that of PCT public service, to one of private interests and private profit. A few rounds on golf course followed by sharpeners all round at the 19th; and before we know it, naturally enough, private commissioners will be commissioning private services on a grand scale. The project to privatise the NHS will be well under way; in perhaps a decade, the NHS will be indistinguishable from the railways and the utilities. Delays, cancellations and over-crowding; Byzantine tariffs and bills that JK Galbraith would struggle to understand. Don’t for a moment think it wont happen: it will – we’ve seen it all before…
So, in summary: the Secretary of State will be relieved of responsibility, and reduced to flag-waving; the arms-length autonomous NCB will do what the hell it likes, GPs on CCGs will be squeezed – and those who wont go quietly suffocated – out, and private commissioners will take over, and nurture private providers. All that remains to achieve full privatisation – the third layer of privatisation, that of funding, by private health insurance – will easily and naturally fall to those already so well placed to offer it – the private concerns already doing commissioning. Job done!