The Patient is Dying
Tomorrow, still basking in afterglow of Tony Blair's thunderous platitudes, most of the delegates to the Labour Party conference will snore through the complexities of a policy which spells the end of everything their party once stood for. The motion calling on the government to abandon its privatisation of the health service may well be passed, but unless they leave the conference centre with the prime minister's head on a pike, it won't make the blindest bit of difference. Only a massive and sustained revolt by the membership of the Labour Party can now save the NHS.
If that sounds like an exaggeration, take a look at the new "diagnosis and treatment centres" (DTCs) whose private operators the health secretary John Reid listed a fortnight ago. These are the clinics to which hundreds of thousands of NHS patients will now be sent for routine operations. Reid insists that the private operators will provide cheaper services than the NHS, cut waiting lists and offer patients a choice of where and when they have their operations. All these claims already turn out to be untrue. But they will succeed in destroying the last pretence that the health service is not being privatised.
At the beginning of this month, surgeons working at the Oxford Eye Hospital wrote to their constituency MP Evan Harris. The hospital, they maintained, had done everything the government had asked. It performs cataract operations at 10% below the price the NHS sets. It is so efficient that, though remaining within budget, it now has surplus capacity. By the end of next year, none of its cataract patients will have to wait more than three months to be treated. The government, as a result, has granted it "beacon" status: it sets the standards to which other hospitals are supposed to aspire.
All this is irrelevant. Dr Reid appears to have promised the private health companies that he will provide opportunities for them, whether or not there is a clinical need for their services. His department claims that the operations performed by the DTCs will be "additional" to those provided by the NHS.1 But most of the cataract operations currently conducted by the Oxford Eye Hospital will now be transferred to a foreign company.
This has happened because two of Oxfordshire's primary care trusts were incautious enough to have expressed an interest in a public (not a private) DTC. That is all they did. But the Department of Health was desperate to find some primary care trusts which would accommodate the corporations. Like the Native Americans who had no idea that they were signing away their land, the trusts discovered that they had mysteriously consented to colonisation.
In August, they wrote to the NHS to explain that a mistake had been made, and ask that their presumed consent be withdrawn. "Detailed discussions have taken place with ... the Department of Health at the highest level.", a leaked response from the health service reveals. "We cannot accede to your request".2
Most of the income the eye hospital receives from the NHS comes from routine operations such as cataract surgery. These subsidise the more complex ones and, being straightforward, permit the hospital to train its surgeons. But it is precisely because they are uncomplicated that the private clinics want to take them from the NHS. The hospital will be left with the difficult cases, a fraction of its budget, and few opportunities for training.
Dr Harris has obtained a leaked memo from the Department of Health to Britain's primary care trusts, which shows that the department has been lying to us.3 Among ministers' promises was a commitment that the private clinics would use only staff who had not been drawn from the National Health Service. But the memo notes that "local staff can be integrated into" the private DTCs.4 However far Dr Reid might bend the definition, I defy him to argue that this does not represent a privatisation of the NHS.
There are two possible justifications for this policy. The first is that it is cheaper. In December the Department of Health insisted that the private clinics would "deliver value for money - through robust, competitive tendering".5 But while it costs the eye hospital pounds685 to perform each cataract operation, the leaked memo reveals that the private company is being offered pounds799.6 One of the reasons why the private surgery is more expensive is that the surgeons who will be flown in to perform it will be paid between pounds450,000 and 500,000 a year.7 Consultants employed by the NHS are paid pounds60,000 a year.8
The second possible justification is that the private DTC will offer better services to patients. In May, the health department explained that the clinics would ensure that "no cataract patient is waiting more than three months by December 2004.".9 But this is precisely the target the eye hospital is already meeting. The department insists that patients will now "have a choice about where and when they are treated".10 But almost all the cataract patients now handled by the hospital will be referred to the DTC. They will be treated in a mobile clinic which will visit their area -- according to the memo -- on only one day in every 10 or 11 weeks. To "save money", the memo suggests that the clinics might operate "on both eyes at once".11 NHS surgeons operate on only one eye at a time, in case an infection leaves a patient completely blind.
If all this seems a little abstract, take a look at what has happened in Canada. In 1996, the government of Alberta announced, just as John Reid has now done, that private contractors would be permitted to perform free operations on behalf of its health service. One of the first procedures to be transferred to the private sector was cataract surgery.
A report by the Consumers' Association of Canada shows that in the regions in which the most cataract operations have been transferred to the private sector, the costs are higher, the waiting lists longer and the choice of surgeons smaller.12 Worse, some of the private clinics appear to be playing on the fears of their health service patients. The clinics have been telling them that the implant of a hard replacement lens is free.
If they're prepared to pay, they can have a "foldable" lens. Its insertion, the clinics explain, is less painful, more likely to succeed, and less likely to lead to infection and blindness.13 This contradicts the public hospitals' advice, that there is no substantial difference for most people. But tens of thousands of patients, terrified of losing their sight, have signed up for the soft lenses. The free service is turning into a paying one.
Somehow, I cannot picture the necessary explosion of anger tomorrow. The members of the Labour Party, frightened that disunity will result in electoral defeat and thus the destruction of Britain's public services, may vote for change, but few will fight to ensure that the government honours their decision. They will preside over the very destruction their unity is meant to avert. I hope they can live with it.
References: 1. Department of Health, December 2002. Growing Capacity: Independent sector treatment centres. http://www.doh.gov.uk/growingcapacity/independentsectordtc.htm
2. Letter from Celia Cohen, Acting Director of Modernisation and Workforce, Thames Valley Health Authority, to Cherwell vale, SW Oxon and Wycombe PTCs, 21st August 2003
3. National Implementation Team, Department of Health, 21st August 2003. ISDTC Programme - Opthalmic Chain. OC - Combined Chain Update.
5. Department of Health, December 2002, ibid.
6. National Implementation Team, ibid.
8. Evan Harris, pers. comm.
9. Department of Health, 21st May 2003. NHS Drive to End Long Waits for Eye-Operations: New £56 million drive to reduce blindness and impaired vision. Press release. http://www.info.doh.gov.uk/doh/IntPress.nsf/page/2003-0206?OpenDocument
10. Department of Health, December 2002, ibid.
11. National Implementation Team, ibid.
12. Wendy Armstrong, February 2003. The Consumer Experience with Cataract Surgery and Private Clinics in Alberta: Canada's Canary in the Mine Shaft. Revised Electronic copy.