Reform, ration, or return to first principles: the choices of the NHS | Letters

Dr Graham Winyard questions the justification for ACOs, Sir Nick Black defends reform, Douglas Higgs calls for a debate about what is affordable and Paul Lewis says there should be a royal commission

As one of Sir Bruce Keogh’s predecessors, I have every sympathy with his desire to defend government policy, however dubious (Chief doctor denies NHS privatisation by stealth, 1 January). But solemn assurances that accountable care organisations (ACOs) are “simply about improving the quality of care the NHS offers” are a little limp, however eminent their source, given that similar claims are routinely made to justify every NHS reorganisation. Remember Patients First, which heralded the introduction of the Thatcherite reforms? As your report highlighted (Private sector dominates NHS contract awards, 30 January), there is such a yawning gap between words and deeds over the creeping privatisation of the NHS that a little study of the small print is worthwhile. Looking at the detail led me to become one of five claimants seeking judicial review of the secretary of state and NHS England’s plans.

Our legal claim is not concerned with whether ACOs are a good or bad idea. It is that such a radical and significant change cannot lawfully be introduced and implemented without public consultation, parliamentary scrutiny and legislation. This will be for the courts to decide; the case papers were filed on 11 December and we are very grateful to the more than 5,000 people who have contributed more than £160,000 to date to make this action possible. However, we also believe that the public and parliament should be very alarmed that by using commercial contracts to set up ACOs the government is exposing the NHS to major risks. If Sir Bruce really wants to reassure us, perhaps he could answer four simple questions.

1) If ACOs are so central to the delivery of effective health and social care, why not set them up as proper public bodies with clear democratic accountability?

2) If ACOs are not opening the door to greater private sector involvement in the NHS, why is their detailed documentation so explicit that they can indeed be private bodies?

3) How can ACOs, whose membership can include private organisations which make money from charges, be trusted to decide what is health care that is free and what is social care that can be charged for?

4) Long-term commercial contracts are hard to get right and expensive to get out of. How can we be sure that 10- to 15-year ACO contracts involving commercial organisations will not lead to similar haemorrhaging of scarce NHS funds as did the private finance initiative, which has left the NHS paying hundreds of millions to offshore finance companies? 

If our fears about ACOs really are so ill-founded, then answering these questions should not be difficult.
Dr Graham Winyard
NHS medical director 1993-98, Winchester

• While increased funding for the NHS in England may prevent some of the problems being experienced and unwelcome measures being taken by our hospitals (Ministers face growing criticism over NHS crisis, 4 January), additional expenditure alone will not create the health and care system we need. This is evident by the fact that in Scotland the NHS spends 13.6% more per capita than England, yet its hospitals are reporting identical problems (Scottish health chiefs issue A&E plea, 3 January).

Even if the NHS in England were to match Scotland and receive an additional £16.6bn a year, we might still face difficulties. The current stress on the NHS seen in both countries is yet further evidence that to achieve a viable health and care system, radical change is needed, as envisaged in the Five Year Forward View, sustainability and transformation partnerships and accountable care systems.
Professor Sir Nick Black
London School of Hygiene & Tropical Medicine

• The short vignettes from so-called experts (How to save the NHS, 6 January) were depressingly superficial and made the same economic error as those originally setting up the NHS: namely that improving the health and longevity of the population would ultimately reduce cost. The opposite is true. If people die prematurely, they cost the NHS nothing. The NHS is a victim of its own fantastic success, but the cost is rising exponentially. Prevention and looking after one’s own health (Cramer and O’Sullivan) is an important priority, but the reality is that in the end we all get sick, costing the NHS, and die no matter how well we look after ourselves. The idea (Milburn) that personalised medicine will decrease the bill is ludicrous. For example, patients shown to have particular subtypes of tumours, using genetic analysis, will be eligible for treatments that commonly cost tens of thousands of pounds per course extending lives by months to a couple of years with the attendant healthcare problems.

Equally the idea of creating better links between hospitals and social services is all well and good, but where do family responsibilities come into this? No mention was made of the hopeless, sclerotic management of the NHS that needs a branch and root reform. Rather than these shallow reheated ideas, we need an honest debate about what the NHS can and cannot deliver within a reasonable budget (how much is the public willing to pay for what?) and, dare I say, how it should be rationed.
Douglas Higgs
Director, MRC molecular haematology unit, MRC Weatherall Institute of Molecular Medicine, University of Oxford

• Every year millions of pounds are poured into the NHS. Every year there is a winter health crisis and every year the NHS is kicked around as a political football by every political party. Before the NHS was established, health care for the majority in the UK was at best patchy and at worst unaffordable and non-existent, with women, children and the elderly suffering the most. Its founder Aneurin Bevan envisaged that in time the establishment of the NHS would improve the nation’s health and that the demand for its services would decrease; the opposite has happened. Currently some 40% of all health problems are as a result of lifestyle choices. Added to this an increasing ageing population with accompanying health and social care needs.

It is now clear that the NHS in it present form is not fit for purpose and that long-term planning and restructuring is required. It is also clear that this task is too important for the short-term vision of all the political parties. We need this to be taken out of the political arena and placed with a royal commission made up of experts in the fields of medicine and health and social care who would be charged with planning a National Health Service for the next 30 or more years, not the current five-year political cycle.
Paul Lewis

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