Coffee House

Time’s up for the NHS monopoly

8 February 2013

Is it time we faced up to the fact that the NHS itself is the reason for the continuous stream of scandals? It’s not just the Mid Staffs Foundation Trust, or the ‘Nicholson Challenge’ or ‘the reforms’, or ‘the culture’. The NHS suffers from systemic faults. Above all, the regular flow of defects and failures is what you would expect from a command-and-control regime that has a monopoly.

It’s not as though making this claim is new. The last Labour Government recognized the structural flaws in the NHS nearly a decade ago. The NHS Improvement Plan of 2004 specifically denounced monopoly: There would be ‘contestability … so that patients and the public, rather than monopoly institutions, can make choices about where, when and how care is delivered.’ Giving people greater personal choice would give them ‘control … allowing patients to call the shots about the time and place of their care, and empowering them to personalise their care to ensure the quality and convenience that they want.’

As a result, there was a big push for ‘contestability’ and patients were told that they were now consumers with choices that put them ‘in the driving seat’. The Government came up against strong entrenched interests and Tony Blair famously declared war on the ‘forces of conservatism and reaction’ in the public sector. The government report, Creating a Patient-Led NHS, said in 2005: ‘At its worst, the NHS has a very hierarchical tradition with professional divides and bureaucratic systems and inflexible processes. These can get in the way of good patient care.’

Since then, the battle lines have been drawn between monopoly NHS insiders  and the champions of the consumer. The monopolists want to suppress competition from alternative suppliers, claiming that it is incompatible with the public-service ethos. The Francis report has finally shown that meretricious claim to be utterly unfounded. On the other side are critics who argue that the best way to encourage high standards and value for money is to promote pluralism, so that the best ideas can emerge from comparison of one provider with another. No doubt in every walk of life the insiders would like to be ‘preferred providers’ with no irritating rivals compelling them to raise their game. But we all know as consumers that, unless we have alternatives, producer interests come to dominate.


Since Blair’s time there has been a steady increase in the involvement of the private sector. Provision of diagnostic services has been vastly improved and the Independent Sector Treatment Centres have been a success. Unfortunately Labour’s commitment to pluralism was weakened by its simultaneous attachment to performance targets. Lacking any real sympathy for pluralistic rivalry, its reforms were increasingly reduced to target-setting.

Professionals and other employees, whose work unavoidably depends on judgment and individual conscience, typically react badly to compliance regimes. GPs notoriously seized on the reforms to advance their own narrow interests. In the first year of their new pay deal, called the Quality and Outcomes Framework, they increased their average pay by about 30 per cent. In many cases they stopped providing an out-of-hours service, when no doctor who truly cared about his patients would hand over the out-of-hours service to anonymous subcontractors.

Some hospitals were soon found guilty of extreme negligence. The Healthcare Commission’s report in 2009 found complete failure at ‘virtually every stage’ in the care of emergency admissions at Stafford Hospital. According to Sir Ian Kennedy, the commission’s chairman,  ‘There is no doubt that patients will have suffered and some of them will have died as a result.’ There were ‘too few doctors and nurses, vital equipment was not available when needed, patients did not receive the care they deserved and the trust had no system in place to spot when things were going wrong.’ Some wards  were filthy, with blood and excrement caked on surfaces; and some nurses were unable to operate cardiac monitors or intravenous drips, which meant patients were not receiving the correct amount of fluid.

During the same period, the annual survey of NHS staff found that many would not want to be treated in their own hospital, suggesting that Stafford was not unique. The Healthcare Commission asked employees of all acute NHS trusts in 2006 if they agreed with this statement: ‘As a patient of this trust, I would be happy with the standard of care provided.’ Under half replied positively: 42% agreed, 25% disagreed and 32% said they neither agreed nor disagreed. In ‘large acute’ trusts only 34% agreed. In 2007 the survey asked staff in all acute trusts whether, ‘Care of patients/service users is my trust’s top priority.’ Only 48% agreed, 23% disagreed and 28% sat on the fence, neither agreeing nor disagreeing.

Compliance regimes operate by remote control, whereas pluralism makes it easier for organisations to emerge that put patients first without compromising respect for the professionalism of staff. Compliance systems treat employees as self-interested individuals who must be incentivised by managerial sticks and carrots to behave in specific ways. As a result, they drive out alternative ways of motivating staff. Pluralistic competition gives rival providers more scope to try out different way of encouraging the best in people.

In a personal service like health care, the first line of defence is the conscience of the individual doctor or nurse. Remote performance targets put external compliance before internal morals. They tend to de-professionalise and encourage cynical gaming of the system, often with harmful clinical consequences. The requirement that hospitals should ensure that no one waited more than four hours to be treated by an accident and emergency department became one of the most abused targets. Some patients were made to wait on trolleys parked in corridors before they had been fully treated, so that they could be ‘signed off’ as discharged within the time limit. Other sick and injured patients were kept in ambulances in the hospital car park because the four-hour clock did not start ticking until the patient was brought inside the building. Similar manipulation became widespread.

If the latest scandal does not trigger a fundamental challenge to the NHS monopoly, it will soon become only the latest in a regular series of similar outrages. The Government has typically reacted by ‘doing something’ that can plausibly be portrayed as useful. But a new hospital inspector will not get to the heart of the problem. We should look overseas to the social insurance schemes of France, Germany and elsewhere for better ways of guaranteeing health care for everyone, whether rich or poor.

David Green is Director of Civitas.

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  • Malcolm_E

    So, if the basic argument is that when a state
    sector service fails, it needs to be privatised, does the reverse argument also

  • Curnonsky

    Apparently there is a little-used method known as “capitalism” which is designed to empower the consumer by fostering competition. Perhaps a dose of this would help?

    • Fergus Pickering

      Capitalism is not designed at all. It grows withot design. That’s what I like about it.

  • David Lindsay

    No, time is up for the England-only dismantlement of the NHS, begun under Blair and continued by his Heir.

    Only in England is the NHS being dismantled. On this as on so many issues, people in Scotland, Wales and Northern Ireland are still permitted to live in a recognisably British country. Given the option, so would people in England. What is happening to our Health Service was not in the Conservative or the Liberal Democrat manifesto in 2010. Had it been in the Conservative one, then there would have been a Labour overall majority.

    Therefore, Labour ought to demand an England-wide, England-only referendum on the Coalition’s plans for the NHS. Not in 2017, but this year, and as early as possible this year. This is, in point of fact, about the constitutional status and the fundamental identity of England as a British country. The easily predictable result would properly banish once and for all the presently ubiquitous Loony Right. With its immediate access to both parts of the present Government.

    And with its highly favoured access to Any Questions, Question Time, Newsnight, the Today programme, The Daily Politics, and so on. Those might then have to give space to some authentically British voices, of One Nation politics, with an equal emphasis on the One and on the Nation, and which not only understood that the two were inseparable (the Loony Right fully understands that, just as the Loony Left did 30 years ago), but which celebrated each precisely by reference to its inseparability from the other.

    • Nicholas chuzzlewit

      This posting is somewhat less intelligible than your usual efforts so perhaps you could clarify a few points for us all viz:
      1. When was the dismanling of the NHS authorised and what form is it taking? I suspect that Cameron will be aghast to learn of this process as he has always been most grateful for the support he and his family received from the NHS in respect of his son.
      2. In the wake of the report on the MSHT where 1,200 people died uneccessarily during Labour’s most recent custodianship, might it not be a good idea to consider carefully how health provision might be reorganised to suit the patients rather than the producers? Sacking the incompetent, callous and indolent doctors, nurses and administrators might be a good start.
      3. It would be rather ironic if Labour demanded a referendum on the NHS while denying the British people a referendum on Europe. It would at least give Cameron a laugh if Milliband “demanded” one. Furthermore, if you believe the result to be a foregone conclusion, although you make no mention of the actual question we will be asked to consider, why bother?
      4. Why is anybody who disagrees with your (admittedly somewhat totallitarian) views automatically branded a loony? I assume it is because you believe only in a democracy of those committed to a left wing ideology rather than the awkward type we currently favour but please enlighten us.
      5. Your final paragraph is barely literate and verging on hysteria but again please enlighten us. Or calm down

      • David Lindsay

        how health provision might be reorganised to suit the patients rather than the producers?

        Vintage Blairism. Which caused the problem.

        It would be rather ironic if Labour demanded a referendum on the NHS while denying the British people a referendum on Europe.

        That’s David Cameron, who knows full well that he is not going to be in office after 2015, nor would anyone else in the EU be remotely interested in his back-of-the-beermat ideas for “renegotiation”. In any case, why would it be “ironic”? People really do care about the NHS. For good or ill, no normal person, by definition, cares about the EU.

        Thirty years ago, this country had a noisy Hard Left, including a very noisy Loony Left. That was given acres of media space from which to promote policies far outside the mainstream, often including submission to the dominating influence of a foreign power, which may or may not have had any real desire to dominate the United Kingdom, but that is not quite the point.

        Today, this country has a noisy Hard Right, including a very noisy Loony Right. That is given acres of media space from which to promote policies far outside the mainstream, such as the dismantlement of all public provision and the repeal of all social protection, and including submission to the dominating influence of foreign powers, or arguably of a single foreign power based on two continents.

        Those opinions are routinely broadcast as if they were uncontentious and commonsensical by shockingly ubiquitous people, who are on the airwaves morning, noon and night to promote the abolition of the minimum wage, the dismantlement of the National Health Service, and so on.

        • Nicholas chuzzlewit

          Loony this and loony that, shockingly ubiquitous (bizarre), no normal person etc – you really hate people who disagree with anything you say don’t you. I suspect you find democracy very hard to live with what with all those different opinions. I certainly favour creating a health service where the patient is sovereign and I favour abolishing the minimum wage in favour of creating jobs and competitiveness. I also feel that we need to debate these issues now despite arrogant people like you who invariably know what is best for the rest of us. I think you need to tone the hysteria down a little however because your arguments are becoming increasingly incoherent.

          • David Lindsay

            They are not “incoherent”. They are just being made by someone whom you can neither sack nor evict, and you have no absolutely no idea how to deal with that.

            • Nicholas chuzzlewit

              How predictably arrogant. You are nobody important, relevant or interesting and thus I have neither the need or inclination to ‘deal’ with you. I simply enjoy pointing out the intolerance and loathing of plurality that left-wing people such as yourself constantly exhibit.

  • Reconstruct

    Have you ever worked for a company which has a monopoly? One of the characteristics is that you end up actually hating your customers, because they have a habit of interfering with the other things you like to spend you time doing (office-politicking, for example). And anyway, it’s not as if they’re going anywhere.

    When you read of what happened in mid-Staffs, it seems plain to me that what was going on was not that the staff neglected the patients, but that they actively hated them and actively inflicted cruelties upon them. I just get the feeling that the damned patients were getting in the way of what the staff valued doing.

    It absolutely does not surprise me Sir David Nicholson rose to the top ‘in spite of’ his time as regional boss of mid-Staffs, during which time he described the complaints of those whose relatives had been on the wrong side of the body-count as ‘simply lobbying’. Neither does it surprise me that he runs up surprisingly large expenses etc etc.

    The fish rots from the top. And when its a monopoly, there’s nothing to stop it spreading.

    • Fergus Pickering

      You may be right. British Rail employees certainly conspired against the passangers. And now it’s all broken up the employees are much nicer. On the other hand, the worst nurse I have ever come across, a real old cow, worked for a private care home.

  • Russell

    Polly Toynbee’s words from summer 2008, as shown by Guido prove without doubt that both her and Labour were in denial even about the NHS.

    “This anniversary week the NHS has never been in better health.
    Never good enough, but now is the golden age on just about every
    available measure. No deficit but a surplus, no winter ward closures, no
    annual crises. Best of all, mortality amenable to healthcare figures –
    the avoidable death rates – now show a 21% improvement, far more than
    any other EU country. As those figures cover only 1998 to 2003 before
    the big spend, they are expected to have improved sharply”

    When are the media going to question Toynbee and Labour?

    Delusion, spin, smear, incompetence and deceit sum up the Labour party.

  • Nicholas chuzzlewit

    I simply do not believe that the political will exists to enact the radical solutions necessary to make the consumer sovereign. After the initial horror has subsided, MSHA will become just another deadly milestone on the long road to disaster which is the NHS. It is outrageous that people responsible for the needless death of vulnerable patients, many elderly, are still working within the NHS and we, the poor consumers, are paying for them. Think about that, we are paying people to be incompetent. If we are unable to fire these amoral, indolent and callous people how can we contemplate radical reform?
    The NHS harbours incompetent doctors, nurses, managers etc just as every other large organisation has its share of incompetents. We need to recognise this simple truth and empower management to remove these people permanently and not move them sideways within the NHS. Second, we need to ditch these ridiculous Stalinist targets and recognise that competition drives up standards and puts the patient/consumer in charge. They manage this acceptably well in Germany, France, Sweden etc so let us start doing the same here. The NHS is not a national treasure it is a national shame and it is about time somebody had the courage to recognise this horrible truth, start taking on these vested interests, begin a programme of meaningful competitive reform and most important of all, ignore the carping voices of the Labour Party..

    • telemachus

      The most shameful post I have read in a long time
      The doctors and nurses you want to sack have taken years to train and need motivating not whipping

      • Nicholas chuzzlewit

        Dear George, Charles, Cindy, Carol, Pauline, Ed, Yvette etc etc and all the rest of you at the Labour party HQ instant rebuttal unit, What is shameful is that 1,200 people died uneccessarily at a major Health Trust under the supposedly caring eye of the last Labour Government and despite spending vast sums of money the country could not afford. These are inconvenient facts that you cannot revise however hard you may try. That is truly shameful. In any event, what is wrong with sacking people who prove to be indolent, callous and incompetent or should we simply ignore this report because it reflects badly on Labour and has nothing to do with all those cuts? By the way, do you guys have a Christmas party because I bet it is a singularly dull and sanctimonious affair.

        • telemachus

          Shameful indeed
          No one would ever have known if the last Government had not put in place the quality mechanisms to drag every hospital up and not hide the errors as had happened during the dreadful 18 Tory years that preceded the major investments after 1997

          • Nicholas chuzzlewit

            Hilarious. There must be 30 or more of you and all you can manage is incoherent nonsense. Jean, Terry, Bill etc you guys are priceless. No wait, you are charismatic superstars!

  • Mark Myword

    But how do we get from where we are to a social insurance scheme? Any such transition would require cross party support because it cannot be done overnight and it would be potentially unstable without such cross party commitment. Then the legislative, administrative and insurance implications take time to work out and work through, and the staff and public have to be taken along also. Whilst I do not disagree that such a scheme could produce better care outcomes, the analysis above focuses only on general hospital care. What about primary care (including care in the community), mental health care, personal social care, specialist (tertiary) care, emergency care, childrens care (both ante and post natal). Can they be underwritten? Then there is the vast amount of clinical education and research undertaken in the NHS – would that be paid for by insurance payments of patients. The recent discussions about care in old age and how it can be insured illustrate the difficulties that can arise. Nothing is impossible, but it is glib to assume this transition would be easy.

  • HooksLaw

    Once again we see a director of a ‘much vaunted’ think tank showing that he cannot walk and chew gum at the same time.
    This is from labour’s manifesto (Labours!) – they promised
    ‘the right in law to choose from any provider who meets NHS standards of quality at
    NHS costs when booking a hospital appointment ‘

    So there is nothing new in calling for outside providers. As for turning the NHS on its head – thats fine until you face the practical and political consequences. talk moif private insurance is all very well until you look at the charges and what you get for them and of course what about children and pensioners? And the mentally ill? And the disabled who cannot work? There would still be a major tax burden and government involvement.

    BTW in this manifesto Brown promised
    ‘radical reform and change across the NHS’ – a good idea until someone else tries it.’

    But what the Staffordshire episode has show is that the NHS is not the flawless paragon that Labour pretend and makes the argument for the very reforms that the conservatives have made. Fundamentally problems like Staffordshire come from trying to meet politically led targets.

    • realfish

      ‘…But what the Staffordshire episode has show is that the NHS is not the flawless paragon that Labour pretend…’

      Far, far, far from it. And still, this day, Friday 8th Feb, after all that has emerged the apologists, the vested interests talk of our much loved NHS. My lunchtime news, tell me that Stafford is not all bad, they did treat some patients well (which is their day job) and a senior doctor told BBC Midlands Today viewers the hospital does have supporters. Well that’s a relief then, I really need to try harder to put to the back of my mind that only 1200 people died there. Mind you, the BBC is a great help, any reference to Stafford has all but disappeared from their web-site and they’ve not been able to track down Andy Burnham for an interview.

      Labour, the BBC, the Guardianistas, and those vested interests are in full ‘Save the NHS’ mode, which rather proves the point that their Stalinist ‘get what your given and be grateful’ edifice is more important to them than the patients that it purports to serve.

      The left have had a tricky job this week, trying to maintain their firewall around the NHS – protecting it from scrutiny and criticism. But even last night, as more unnecessary deaths and ill treatment became apparent, the BBC QT audience was able to rally round and applaud an organisation that has, for a long time, not been ‘fit for purpose’ and is killing they and their families. How does that happen? How has this mythology, this worship of a phoney (Olympian, no less) god come about?

      Little chance then that any Government can ever deliver the reforms that the people deserve. Perhaps the only possible way is to start again and Gove-like, establish a network of clinician-led ‘free hospitals’ to run alongside the old and discredited dying edifice until such time that a new culture can emerge. If you free the people from their obligation to worship the NHS and show them what a health service should look like, they will soon vote with their feet.

      Save the NHS? No! destroy it and save the patients


    I believe too that there are too many left wing people at the top of the NHS who are only in this for money they are not interested in patients or what the dorctors and nurses are saying. under Labour and their mass immigration the NHS has been obliged to take foreign nurses regardless of whether they were fit or not and the NHS bosses have favoured this and so they have got rid of our home grown nurses for these people . to me doctors should run the NHS they not what patients require they also know what standard of care the nuses should be giving. some of these immigrant nurses barely speak english and they push you about because they think it is being efficient. 10 mins the doctor is given for each patient which is rediculous . and because of the influx of all these paople it has swamped the hospitals and people who have paid taxes all their lives are being short changed and priority is given to these people by the managers and above.

  • In2minds

    Much as we have free schools we need hospitals freed from the present state serving system. Put the public first, they pay for it.

  • Chris lancashire

    A way needs to be found to take the state – and politics – out of health care (I am afraid I have no suggestions how to). In many European countries the state is not directly involved in running healthcare which often results in a far superior service – France and Spain to name but two.

    • HooksLaw

      Well the latest reforms do something for that. I believe the minister loses his power to intervene – though I cannot remember the exact turn of phrase.

    • Colin

      Start with the unions. They’re in the process of blighting everything from healthcare to education. The NHS is now the new Racism – i.e. impossible to have a grown up debate on the subject.

    • telemachus

      There is in fact no way to divorce healthcare from politics
      We have limited resources and therefore you need choices
      You can make choices purely economically which is unjust for the poor or make them for and by the people which is politics
      If you are into referenda you can do it the Oregon way, again politics

      • starfish

        Strange, I thought choices were made based on medical need

        Which is what one would expect of a healthcare system

        Maybe that is where they are going wrong

        • telemachus

          No many on cost
          Think cosmetic surgery
          You can have this if post cancer treatment but not if not.

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