The beginning of the end

INDUSTRIES and banks may be sliding into recession worldwide, but private health-care providers have a smile on their face.

They're looking forward to rich pickings from our National Health Service. They love the government's determination to divert a growing share of the NHS budget from public services to the private and "independent" sector.

According to HealthInvestor magazine, "The UK health-care market has remained resilient, stable and remarkably active despite the financial volatility.

"The combination of the government's NHS reform programme and the sector's strong fundamentals enables venture capitalists, private equity and banks to proceed with opportunities difficult to find in other sectors."

The speculators are right to regard Gordon Brown's government as their sponsors. Behind the scenes and out of the headlines ministers are forcing through a massive new drive towards fragmentation, privatisation and marketisation of the NHS, reviving proposals which appeared to have been abandoned almost four years ago.

The main target now is primary care and community services, delivered until now by primary care trusts and employing around 250,000 health workers in England.

They now face a three-pronged onslaught from far-reaching government policies which few people will even be aware of:

There's World Class Commissioning, the apparently meaningless mantra of cliches promoted over the last year or so by strategic health authorities and primary care trusts as they set about splitting up and outsourcing services.

There are the proposals contained in Lord Darzi's Next Stage Review and other policy guidance to boost the creation of "social enterprises" - private-sector organisations which generate surpluses from providing health care, but do not distribute profits or dividends to shareholders.

And there's the establishment of a new hard-nosed body, the so-called Co-operation and Competition Panel, with a brief to force through a new, competitive market system in what has until now remained one of the more integrated areas of health care.

In July 2005, just after the general election, then NHS chief executive Nigel Crisp attempted to split directly provided services off from the primary care trusts, suggesting that the latter should simply become commissioning bodies with huge slices of their services hived off - privatised, handed over to "social enterprises" or run at arm's length until some alternative could be found.

Crisp was looking at a model in which the NHS would effectively cease to be a provider of services. Instead, it would become a fund to purchase services from a range of providers, whether these be foundation trusts, the private sector or social enterprises. These would compete with each other for business and their services would be "commissioned" by primary care trusts which would hold the purse strings locally.

Crisp called his plan Commissioning A Patient-Led NHS, although there was no hint anywhere in his rambling and vague circular on how patients would have any say at all in the proposed reorganisation.

In fact, the Crisp plan involved the merger of 25 strategic health authorities into just 10 even more remote and more arrogant super-quangos and the forcible merger of over 300 primary care trusts into half that number, again forming much bigger and less accountable organisations than before paying only lip-service to public involvement.

This part of the plan was carried through, but Crisp's rapid-fire proposals to hive off the primary care trusts' directly provided services proved far more controversial. Ministers were forced by a tide of public anger to intervene and slow the process right down.

Now, four years later and long after a disgraced Crisp was dispatched to the House of Lords with a fat pension pot, they are coming back to try again. The buzz phrase for their plan is World Class Commissioning.

It would focus primary care trusts on 11 "competencies," many of which are only included to divert attention from the central objective of creating a health-care market. The latter is spelled out in Competency 7 - "Effectively stimulate the market to meet demand and secure required clinical and health and well-being outcomes."

This means ensuring that a variety of providers competed for contracts to deliver services - in other words, inviting in the private sector and social enterprises to take a slice of every local NHS budget.

Primary care trusts are rated on their achievement of the various competencies and strategic health authorities, not satisfied with the level of privatisation that has been delivered, are pressing them to step up their efforts and bring in more private-sector providers, especially in primary care.

Even Camden PCT, which defied local protests to hand over three GP practices to US privateer UnitedHealth last year, has been found inadequate in its privatising efforts.

It was given the lowest score by NHS London, which is setting up a powerful and costly structure - the London Clinical and Business Support Agency - to harness together the capital's 31 primary care trust. It's headed up by health privateer BUPA's former boss Rhona McLeod and will seek to co-ordinate the drive towards a health-care market in the capital.

The Department of Health is also gearing up for the government's marketisation drive. Its guidance on World Class Commissioning repeatedly refers to the "framework for procuring external support for commissioners," which brings together 14 companies that have been "approved" by ministers to advise primary care trusts. Three of the major US health insurers whose trustworthiness was so strongly questioned by Michael Moore's film Sicko have a seat at the table.

Nowhere do ministers make clear exactly why these private profit-seeking companies should themselves be seen as "world class" or what appropriate skills and knowledge they may have to offer NHS organisations tasked with delivering a universal and comprehensive health-care system to the whole local population.

World Class Commissioning involves many "competencies" in addition to stimulating local markets and not all of them have dangerous implications that will fragment and undermine services and funnel NHS cash out to bolster private profits.

Primary care trusts are also urged to become "recognised as the local leader of the NHS," to "work collaboratively with community partners," to "proactively build continuous and meaningful engagement with the public and patients," to lead "continuous and meaningful engagement of all clinicians" and many other worthy objectives.

But much of this is window-dressing. Ministers know that there is no public pressure or support for many of the big changes they are imposing on the PCTs and that the only public views they will consider are the ones which seem to echo their proposals.

The primary care trusts are being fashioned into instruments for top-down control by ministers and strategic health authorities seeking to break our once-unified NHS, with its planning and targeting of resources, into a competitive market - whether we like it or not.

John Lister is information director for London Health Emergency.