Lynne Jones MP - April 2003
After several years perpetuating Tory underfunding,
the Government is at last putting big money into the NHS.
But it is so obsessed with the need to achieve short-term results like
reducing waiting times for non-urgent surgery that it is subjecting the NHS to top-down
reorganisation imposed under the guise of modernization and decentralisation.
The latest fad, foundation hospitals, came about
after Alan Milburn visited the state-owned but privately-run Fundacion Hospital in Madrid. He
was impressed that Fundacion outperforms government controlled hospitals. (Local unions suggest this is because the most
costly and difficult patients are sent to a nearby fully public hospital and average
working hours are 8% longer than normal!) Milburn
wants foundation trusts to unleash public sector entrepreneurialism and
innovation giving accountability to local communities.
The Government is desperate to justify increased spending on the NHS from taxation,
fearing that the affluent middle classes might be tempted to switch support towards more
private insurance to get more choice. Yet real choice can only be provided if there is
surplus provision, which may be OK for general goods and services but inefficient and
massively more costly when it comes to essential public services dependant on highly
skilled staff and complex equipment.
Even the BMA has pointed out that foundation
hospitals risk replicating the bureaucracies of the internal market in health care that
Labour pledged to abolish and so ministers have propagandised that foundation trusts are
in line with a co-operative and mutualist tradition. This
is a selective re-writing of history. Co-operative
societies are associations that bring members together for purposes of providing benefits
to members and the sharing of profits. By
contrast, foundation hospitals would be hugely complex organisations delivering a public
service. They are supposedly to be locally
owned but the Secretary of State has not explained how Members can
own the assets of new PFI hospitals!
Foundation hospitals will
operate on a not-for-profit basis and will have a board of governors drawn from a
self-selecting "membership community" of residents, staff and service users who
have actively opted to become members of the trust. Only
three star hospitals can bid for foundation status, despite the governments rating
system being based on a limited range of performance indicators that measure quantitative
targets such as waiting times and financial performance, not clinical outcomes and quality
of care. To counter charges that they will
select who they treat and the services they offer, they will be licensed by a new
regulator and required to deliver their existing range of services to national targets and
standards, subject to inspection by the Commission for Healthcare Audit and Inspection. There will be a cap on existing levels of private
work and a new mandatory "national tariff" for all health care procedures will
ensure that foundation hospitals cannot undercut other NHS hospitals (although this will
raise other concerns that standard prices will introduce incentives to compromise on the
quality of care).
Foundation trusts will be able
to borrow from both the public and the private sector, and will retain any operating
surplus they may earn. Private sector
borrowing will be under the control of the licensing regulator, who will rule on
compliance with a borrowing code based on the hospitals ability to service its debt.
In reality, the control on these
so-called autonomous bodies by numerous quangos will mean that their freedoms
will look more apparent than real. The system
is destined to lead to further voter apathy at national and local elections as the public
becomes even more confused about where responsibilities lie.
Whilst foundation trusts will
apparently be forbidden from poaching staff, the effect of the first wave of
foundation hospitals in a situation of prolonged staff shortage seems likely to boost
recruitment at these elite institutions at the expense of the rest of the NHS. The effect of encouraging consumer choice in schools
has been that the poorest schools enter a spiral of decline from which they cannot
recover. Is there any reason to suppose this
will not happen with hospitals?
The future of the NHS
should be about developing whole systems, not isolated institutions; about building
networks across professional and institutional boundaries, not creating new barriers;
about sharing IT and information, not reducing connectivity, and about getting more people
treated in the community and in primary care, not sucking them into hospitals. The danger with the reforms is that they do exactly
the opposite and will return us to the fragmentation of the pre-NHS era and render public
services ripe for privatization. It is not
surprising that foundation hospitals, like that other folly, the invasion of Iraq, have received more support in Tory circles than they ever will
Acknowledgements to the Socialist Health Association
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