“I don’t know how much any of you realise that with the Lansley act we pretty much gave away control of the NHS… we don’t really have day-to-day control.”
Jane Ellison, Public Health Minister (June 2014)
In Scotland and Wales, car parking charges at hospitals have been largely abolished. That’s one of the consequences of devolution.
In England, car parking charges at hospitals still exist because the NHS in England is a network of property companies run on behalf of bankers. That’s one of the consequences of Andrew Lansley’s £3 billion reorganisation that was in nobody’s manifesto.
It’s also what became clear last week when ministers published newguidelines on parking charges that sought to address the chief complaints about the system, especially from folk with disabilities and from staff whose shifts mean they can’t use public transport. These guidelines are just that. Guidelines. The Health Secretary has no power to compel NHS providers to comply.
That would be fine if the NHS providers were accountable in some way to a democratic institution locally that did possess the power to compel. It’s not fine at all that they appear to be simply unaccountable. The warming-up of the English NHS for privatisation has been presented as a hands-off policy freeing clinicians to make their own judgements on patient needs and the best way to meet them. They will be held accountable for clinical outcomes but nothing more. So the management of publicly-owned assets built up over many decades passes out of democratic sight. Unelected bodies are handed huge amounts of public money that is to be used to achieve specified objectives, yes, but with the ability to adhere to or to ignore other objectives at will. Objectives that might seem peripheral to the core aim of the NHS but which nevertheless have an impact on our lives.
The united aim of the London parties is to take the NHS further down the privatisation road. They really will do anything to avoid direct responsibility for the well-being of those who elect them. So we can expect to hear more about empowering the unelected managers of trusts and foundations and commissioning groups to make their own decisions. Decisions about what to do with our assets and our money. But these are not our decisions. And if they’re decisions we don’t like, then we have no redress.
It’s so very easy to cheer-on the stripping-out of democracy. ‘Good thing too. Get the politicians out of decision-making. Put the experts in charge.’ Then again, if you find yourself at the hospital, visiting a dying relative, and without the right change for the parking, the penny must drop even for the densest of Daily Mail readers.
The boundary between what is debatable as policy and what is to be delegated as mere administration is being pushed further and further in the direction of empowering an inaccessible oligarchy. Inevitably, the more centralised the system, the more pressure on its rulers’ time and so the smaller the realm of policy and the larger the realm left exclusively to the bureaucrats. Eventually, something big goes wrong at the sharp end; the politicians say ‘nothing to do with us’ and present privatisation as the answer to the ‘lack of accountability’ inherent in a system that they designed to fail.
In 1948 the NHS was deliberately set-up within a Government department – and not as a public corporation, like the nationalised industries – because it was seen as a service and not as an industry. It was to be run on lines of Parliamentary scrutiny and ministerial accountability, not commercial performance or independent access to the capital markets. It has since fallen victim to a cross-party consensus that is far from unique (since education and the fire service are going the same way), one that combines long-term guile on the part of its promoters with short-term stupidity on the part of its receptors in a currently winning formula. One that views turning all caring into a profit-seeking business as the only means of motivating staff to do better with increasingly constrained resources.
Patients can expect more respect as customers, surely? Why? The contract isn’t with them personally and the ultimate truth is it’s then the money that motivates, not them at all. Going the extra mile won’t happen if it wasn’t allowed for in the bid. Costs increase as the moral hazard is to order more stuff that can be charged for, even when not really needed. Nobody is transparent about their costs any more, because that becomes a matter of commercial confidentiality.
In Somerset, NHS Trusts are in the process of being reorganised, not on the basis of what they can do for patients but on the basis of their financial prospects. This is a requirement of the Lansley act, which forces every NHS Trust either to become a full-blown Foundation Trust or to give up, for example by handing over to a private contractor. Weston Area Health NHS Trust is England’s smallest Acute Trust (someone has to be), yet ranks as one of its top six for clinical efficiency, and has the smallest percentage of patients readmitted to hospital within seven days. So it’s not surprising to see it being destroyed. As with academies, the new language is that of mergers and acquisitions, of chains and groups; soon it will be the language of share options and directors’ bonuses. Public money, private pockets.
We need to be abundantly clear that our own aim is democratic decentralisation. Democratic institutions without the decentralisation of real power are a facade behind which centralist interference in local affairs continues unabated. Decentralisation without democracy is a sell-out (often literally) to a managerialist form of tyranny that is no improvement.