With the health bill passed, the government is now setting about forcing the market into the NHS. Colin Leys looks at what is likely to happen next
This is already happening. People who suffer from a range of conditions that are not life-threatening, but are often painful and even disabling, are being told to pay for treatment or go without. The health bill will make this more common, and taking out private insurance for such problems will become widespread.
At the same time the government plans to expand the use of personal health budgets, administered for us by ‘intermediaries’. Coupled with the normalisation of private health insurance, personal health budgets could easily become a tax-funded subsidy for private healthcare for the better-off, triggering a further contraction of free NHS care for the poor. New charges or ‘co‑payments’ also look likely for some aspects of NHS care.
It has become urgent to see how this chain of developments is likely to evolve.
Under the bill, clinical commissioning groups, or CCGs, which are unelected and unaccountable, only need arrange for the provision of hospital or community healthcare services that they consider necessary to meet patients’ ‘reasonable requirements’. There will be limits to their power to restrict coverage, but since the justification for introducing CCGs is supposed to be that GPs ‘know what patients need’, a good deal of discretion is going to be left to them. And the private sector ‘support organisations’ that are going to do most of the actual work of commissioning will urge that the list of treatments the CCG will pay for should be kept as short as possible, both to save money and because their personnel will tend to favour private provision.
Services are already being withdrawn
It is already happening, in a semi-secret way. The practice began in 2006 when a primary care trust in Croydon, desperate to save money, put together a list of 34 procedures it considered ‘not necessarily performed for medical reasons’, which it said did not have to be offered to patients in cases where they were ‘ineffective’ or cosmetic. The list included non-cosmetic procedures, including surgery for cataracts, hips and knees, on the grounds that the benefits were minimal in ‘mild’ cases.
Obviously, what is considered a ‘mild’ case of a cataract or an arthritic hip or knee is liable to be modified by financial pressures and by April 2011 the Croydon list was being widely used to save money. According to one well-informed commentator at the time, in some areas only “urgent” treatments – cancer, fractures and A&E – were funded. All other procedures were either delayed or the patient was denied funding. So the ‘postcode lottery’ that used to apply to some prescription drugs now applies to some treatments, or even whole medical conditions, such as varicose veins or disfiguring skin conditions. Some of the conditions listed may sound unimportant, but to a person who suffers from them denial of treatment is far from trivial.
Besides these services there are others that are supposed to be available but are increasingly being denied in practice. Some GPs have been restricted to making four referrals per week, regardless of how many patients in need of a referral they may see. Other GP referrals are intercepted and denied before they reach a hospital specialist. This is being done, explicitly to save money, by privately-run ‘referral gateways’. One of the first was in west London, where the giant US health insurer UnitedHealth has been given the job of vetting, and in some cases overturning, GPs’ judgments.
One west London patient, who had been referred for a replacement after her knee collapsed, was told by the referral gateway to have physiotherapy and painkillers instead. It took more than £1,000 worth of private x-rays and surgeons’ opinions for her to finally prove that she needed a knee replacement and get it done on the NHS. Many patients are less fortunate, or determined. For them, NHS treatment is not free. They must pay to get it privately, if they can. If not, they don’t get treated.
As a result of the health bill, it may not just be GPs’ referrals that are diverted or denied. The more expensive treatments recommended by hospital specialists, which the CCGs are going to have to pay for, could also come under review, and the CCGs could refuse to pay – just like healthcare maintenance organisations in the US. (Remember the doctor in Michael Moore’s film Sicko explaining to Congress how she was paid a bonus related to how many treatments she denied?)
Personal health budgets
Another major change already taking place, and which may have crucial consequences as a result of the health bill, is the rolling out of personal health budgets. At the moment these are to be allocated to some 53,000 people in England who are receiving NHS continuing care for a chronic condition. The personal budgets already used in social care have revealed their inherent problem: they are limited – and financial constraints mean that they are not generous. If a personal budget proves inadequate, the patient has to top it up – if they can afford to. For NHS care, such ‘top-ups’ will be payments for what was previously free.
It is significant that the government describes patients in receipt of continuing care as the ‘first group’ to be eligible for them, implying that personal budgets will be extended to other sorts of patient. The NHS Future Forum, set up by the government in April 2011, went further, recommending that, ‘Within five years all those patients who would benefit from a personal health budget should be offered one.’ The government accepted the forum’s report, and the Department of Health’s impact assessment for commissioning speaks of every patient having a budget allocation.
This raises the possibility that personal health budgets, with personally-paid top-ups, will become the basis of most, or conceivably all, NHS care. This approach is strongly backed by advocates of health insurance. They propose that everyone should have a personal health budget, sometimes called a ‘health protection premium’, paid for by the state, equivalent to the NHS’s average annual spending on healthcare per person. This would entitle everyone to a defined package of entitlements. Anything beyond that would have to be paid for by the individual. For most people that would mean taking out medical insurance for a wide range of other conditions and treatments – if they could afford to, and if insurance was available (pre-existing conditions may not be insurable).
Since 2010–11 the funds distributed by the Department of Health for spending on patients’ acute (hospital) care have been calculated on the basis of the actual health status of every single patient registered with a GP, as reported annually to the department – in just the same way that insurance companies assess whether to offer someone insurance, and if so for what level of premium. This makes a wholesale shift to private healthcare via personal health budgets even easier to manage, especially since insurance companies are going to be involved in the commissioning support groups that will be handling all such data.
The normalisation of private health insurance
To see how this could work, we must start by noting that in 2009, 10 per cent of the UK population already had some form of private medical insurance. This proportion had been more or less static for several years. Greatly increased NHS funding from 2002 onwards had led to a big drop in waiting times and other improvements, which reduced the main incentive to ‘go private’; and then the 2008 financial crisis cut people’s spending power, leading to a small decline in the numbers privately insured.
The insurance industry is confident that there will eventually be a big increase in demand as a result of the health bill. The targets of the costly advertising campaigns recently mounted by health insurance companies are not the rich but people in ordinary jobs. The companies clearly expect private health insurance to become widespread and normal.
This could then easily mesh with personal health budgets to produce a state-subsidised private health insurance system. It would work as follows. Personal health budgets will usually be held and administered by ‘intermediaries’, as they mostly are in social care, and the intermediaries could be insurance companies. Patients with NHS personal budgets held and managed by these companies could then have full private health insurance, with much of their premiums covered by their personal health budgets. They would only have to pay the difference.
This would leave CCGs with the uninsurable patients – those with costly chronic illnesses, and those too poor to pay any premiums. And since the CCGs would no longer have the unspent personal health budgets of the healthier and wealthier patients, who would have been cherry-picked by the insurers, the result would be further restrictions on care for those who remained.
The government will also be under pressure from private providers and the Treasury to allow charges or ‘co-payments’ for some aspects of the NHS care that would still be available free. These would probably begin with charges for consulting a GP and for the so-called ‘hotel costs’ involved in being in hospital, both of which have long been urged by the advocates of privatisation. If and when this happens, the principle of a comprehensive, universal free service will have been comprehensively abandoned.
Colin Leys is an honorary professor at Goldsmiths University of London. He is the author of Market Driven Politics: Neoliberal Democracy and the Public Interest and, with Stewart Player, The Plot Against the NHS (Merlin Press, 2011).