The Great Consolidation
What more can the government shut down? Oh yes, doctors' surgeries.
Everything is getting bigger and further away. Hospitals, post offices, schools and prisons are being "rationalised" and "consolidated". The government says that this process improves efficiency. Instead, it outsources inefficiency: we must travel further to use public services. This is bad for the environment, bad for community life, bad for universal provision. But we haven't seen anything yet. We are about to be confronted with the biggest shutdown of all: the government has started the process of closing England's network of doctors' surgeries.
If you know nothing of this, don't blame yourself. The announcement was buried in an interim report published last October by a health minister(1). The report was 52 pages long, and the policy was explained in a single paragraph on pages 25 and 26. Rather than being brought before parliament, it was released four days before MPs returned from their recess. Since then there has been no further public announcement. But in December the Department of Health sent a letter to all the strategic health authorities in England, demanding that the policy be implemented immediately(2). The greatest transformation in the history of the NHS is taking place without public debate, public consent or formal consultation.
The government's policy is to consolidate doctors' surgeries into a series of giant health centres or polyclinics. Thousands of small practices will be closed and patients will be processed in buildings containing up to 50 GPs. The new clinics will also house some services currently provided by hospitals, which allows the government to claim that it is bringing healthcare "closer to home". The net effect will be a massive reduction in convenience.
The policy was launched by Ara Darzi, a colorectal surgeon who has been raised to the peerage and made under-secretary of state for health. He wrote his interim report in three months, during which he claims to have spoken to thousands of people. But it contains no record of who they are, how they were selected or what their answers were: he reveals only that "their views have helped shape this interim report."(3) His final report will not be published until June, but the Department of Health has instructed England's primary care trusts (PCTs) to advertise for bidders for the new polyclinics by May 2008(4): the first notices have already been posted in the Health Service Journal.
During a parliamentary debate launched by the Conservatives last week, Alan Johnson, the secretary of state for health, claimed three times that this policy is not being imposed on primary care trusts. "There is no national policy," he said, "for replacing traditional GP surgeries with health centres or, indeed, polyclinics"; "we are not specifying polyclinics as any part of the exercise"; "[the Tories say] we are imposing a system of polyclinics throughout the country. We are not."(5) Three times, in other words, he misled the House. The letter sent by the Department of Health in December ordered that "each PCT will be expected to complete procurements during 2008/09"(6). In a parliamentary answer in Febrary, the health minister Ben Bradshaw confirmed that "every PCT in the country will be procuring a new … health centre during 2008-09."(7) A press release published by the Labour Party on April 15th confirmed that the new health centres would be built "in every town and city."(8) I hope MPs demand that Alan Johnson apologise to parliament.
Lord Darzi insists that polyclinics will offer "a more personalised service"(9). This is nonsense: in the huge new centres we are less likely to be able to see the same GP and more likely to get lost in the system. A recent paper in the British Medical Journal reveals that "patients in small practices rate their care more highly in terms of both access and continuity" and that small practices "achieved slightly higher levels of clinical quality than larger practices"(10). The new centres will be built not where they are most convenient for patients but - as Darzi revealed to the Commons health committee - where the NHS happens to own land(11). If you live in a village or a distant suburb and depend on public transport - as many elderly and sick people do - visiting the doctor could take all day. Ara Darzi is the new Dr Beeching, shutting down the branch lines of our primary health service.
So why is this happening? In seeking surreptitiously to privatise healthcare, the government has a problem. Primary care is already in private hands: GPs run their own practices. But they are the wrong hands: the corporations demanding guaranteed streams of income from the taxpayer can't play. Polyclinics are perfectly designed to let them in, while preventing doctors from competing.
It's not just that GPs can't raise the capital; because the contracts are much bigger than ordinary practices' and involve many different services, the tendering process is expensive and fiendishly complex. The big service companies can produce the same bid for any number of clinics: they need spend their money only once. The Department of Health says that primary care trusts should use a type of contract called Alternative Provider Medical Services(12), which is designed to allow corporations to bid. This is not a public-private partnership: it is the outright privatisation of primary healthcare.
Do I need to explain the implications? The US health system, which the British government seems determined to emulate, is both more expensive and less efficient than ours; those who can't afford to pay are either excluded or treated like battery pigs(13). The independent sector treatment centres (ISTCs) - private clinics performing routine operations for the NHS - that the government introduced in England in 2003 have been a costly disaster. Private companies receive their money whether or not they carry out the work they are contracted to do. The government refuses to release comparative figures, but the little evidence we have suggests that their costs are much higher than the public sector's(14). The risks have been transferred back to the taxpayer and in some cases the standards of treatment are appalling. In 2006 Angus Wallace, professor of orthopaedic and accident surgery at Nottingham University, told the Guardian, "We expect failures of hip replacements at approximately 1% a year and knees at about 1.5% a year. But we have got some of the ISTCs that are looking at 20% failure rates."(15) Because they put profits first, companies that run these centres have generated a stack of litigation claims and a huge NHS bill for repairing the damage they have caused(16). Far from reversing its policy in the light of this evidence, the government is setting up a competition panel, to ensure that the health service never discriminates in favour of the public sector when awarding contracts(17).
Did any of us ask for this? Are there crowds on the streets demanding the privatisation of the NHS? Even the Tories, for God's sake, have come out against it: David Cameron's speech last week placed them to the left of Labour(18). Why, after the 60-odd consecutive quarters of growth that Gordon Brown keeps boasting about, can he not maintain a public service founded in the midst of poverty and rationing? What mysterious hold on policy do the corporations possess, that they can persuade this government to wreck Labour's finest achievement and damage its chances of re-election?
1. Ara Darzi, October 2007. Our NHS, Our Future. NHS Next Stage Review: Interim report. National Health Service. http://www.ournhs.nhs.uk/
2. Ben Dyson, Commissioning and System Management Directorate, Department of Health, 21st December 2007. Letter to SHA Directors of Commissioning.
3. Ara Darzi, ibid, p3.
4. Ben Dyson, ibid, para 14.
6. Ben Dyson, ibid, para 5.
8. The Labour Party, 15th April 2008. NHS on your side. http://www.labour.org.uk/nhs_on_your_side,2008-04-15
9. Ara Darzi, ibid, p30.
10. Martin Roland, 22nd March 2008. Assessing the options available to Lord Darzi. British Medical Journal, vol 336, pp625-626. doi:10.1136/bmj.39510.702234.80
11. Professor Lord Darzi of Denham KBE, 25th October 2007. Minutes of Evidence taken before the House of Commons Health Committee. Answer to Q94.http://www.publications.parliament.uk/pa/cm200607/cmselect/cmhealth/uc1106-i/uc110602.htm
12. Ben Dyson, ibid, Annex A.
13. During the Commons debate last week, Richard Taylor MP cited two recent papers about the failures of the US medical system, published in the BMJ and the New England Journal of Medicine.http://www.publications.parliament.uk/pa/cm200708/cmhansrd/cm080423/debtext/80423-0003.htm#08042357000001
14. Allyson M Pollock and Sylvia Godden, 23rd February 2008. Independent sector treatment centres: evidence so far. British Medical Journal, vol 336, pp421-424. doi:10.1136/bmj.39470.505556.80
15. Quoted by Sarah Boseley, 1oth March 2006. NHS forced to fix bungled private sector hip replacement operations. The Guardian.
16. See also Stewart Player and Colin Leys, April 2008. Under the knife. Red Pepper magazine.
17. Nicholas Timmins, 16th March 2008. NHS providers to win right of appeal. Financial Times.
18. David Cameron, 21st April 2008. Speech on Primary Care. http://www.conservatives.com/tile.do?def=news.story.page&obj_id=143765&speeches=1
Published in the Guardian 29th April 2008.