The National Health Service reforms: The Emporer's New Clothes?

No-one can have escaped the furore that there has been over the National Health Service in recent months. There has been much in the national press lately about the current state of the National Health Service.

So why one more article? And why on earth in The Psychologist? Well, I felt compelled to write for several reasons.

Firstly, I am concerned about how current problems in the NHS could affect us as members of the public – ourselves, our extended families and our children. We are all service users of healthcare at some points in our lives. Some of us may be fortunate enough to need minimal care. Others may need longer term or more intensive healthcare, through illness or accident.

Secondly, not only are we users of health care, but so are our clients. And of course, our clients are the people we aim to serve, regardless of our specialty or division.

Thirdly, I am concerned how these changes could affect us as professionals. This has been prompted by recent letters to The Psychologist, such as Smith (July 2006 issue) raising concerns about newly qualified psychologists securing employment, and Burgess (September 2006 issue) highlighting how his Trust is now suggesting employees use annual leave to cover their CPD.

Fourthly, I think the reform in health care is happening too swiftly, with too little consultation with the public. I do not think the general public appreciate the enormity of the changes. If change continues unabated and un-debated, Britain could return to a system of health care where the poorest in society are unable to get care because they cannot pay for it. Whilst many people cannot remember living in fear of becoming ill, there are many older people who can recall a pre NHS era, where people could not afford to call a doctor if they were sick.

It is my belief that psychologists have a role and responsibility to raise concerns about reforms that potentially disadvantage the more vulnerable in Society, and lead to inequalities.

The context

The story begins well before the current and apparent crisis of funding that has been reported recently. As many therapists know, current crises often have their roots in history and context. In the case of the NHS, the problems have been brewing since the 1980's, when there was a shift towards privatisation of nationalised industry.

This shift has continued and current Government policy seeks to move British health care towards a privatised system. This is not unique to Britain, but is occurring internationally and links to changes in the post World War II agreement on trade (The General Agreement on Trade and Tariffs or GATT). The GATT was originally designed to increase trade between countries but also allowed governments to protect their own industries, particularly nationalised services.

However, in the 1995 the GATT was replaced by the World Trade Organisation, which has a stronger emphasis on privatisation, interestingly termed 'liberalisation'. So, there has been a shift over time, moving from considering trade as just concerned with goods (eg cars), to thinking of services as tradable.

In the mid 1990s, the UK and USA developed a new international agreement, the General Agreement on Trade in Services (GATS). This has facilitated the opening up of services, such as health and education, to international competition. This has triggered the changes now happening in health.

Healthcare unions are very concerned about these changes. Many unions, such as UNISON, AMICUS and the BMA, have joined forces under the banner of a campaign to Keep Our NHS Public. Some key messages about the presenting problems of the NHS reforms are these:

•    There are concerns that Foundation hospitals and payment by results will undermine proper planning of services. Hospitals that attract more patients will be paid more. There is concern that less popular hospitals will be unable to stay financially buoyant and may have to close. There are concerns that foundation hospitals may be under pressure not to provide costly treatments. The NHS has traditionally been based on a system of co-operation, not competition. Such a shift in paradigm could lead to a fragmentation of services, and an increase in costly bureaucracy.
•    The patient choice agenda is not evidence based. Patients will be offered several choices of provider, of which some must be private and not necessarily local. This means that the health system will be based on competition, rather than collaboration (as it has been in the past). This will lead to fragmentation, and could mean that many different providers of services become involved in caring for people with complex health problems.
•    Current Government strategy means that Primary Care Trusts (PCTs) have to buy 15% of their services from the private sector. There is concern that this could lead to a proliferation in services to people who can pay for them, as companies will not be interested in providing services which aren't profitable. This will lead to inequalities in service provision.
•    There is concern that planning at local and regional level will be based on commercial priority and the need to generate profit, rather than clinical need. As hospitals are paid for results, there will be pressure to 'disinvest' in services that are expensive or do not make profit.
•    There is a concern that Independent Sector Treatment Centres (ISTCs) will have unfair advantages over NHS providers. They do not have overheads such as training costs, do not follow patients up or deal with complex cases. Naturally, this raises a question about the quality of care being provided.
•    Private contracts, such as Private Finance Initiatives (PFI) have been criticised. This is when private companies plan, build and manage public buildings. The scheme has been criticised for charging very costly rents over long periods of time (25-40 years). The payment of this 'rent' must take priority over budgets for services. At the end of a 'lease' the premises still do not belong to the NHS, they remain with the private consortium.
•    Extra finances have been put into healthcare, but there is concern that money is also flowing out of the NHS into the private sector. For instance, the use of ISTCs in Oxfordshire, saw £255 000 of NHS money paid to a cataract centre in its first six months, for providing £60 000 worth of operations.


How could this affect us as members of the public?

So, what might the impact of this be on us, as members of the public? As service users, we might expect to see some NHS hospitals closing as they cannot remain financially viable. If we have chronic conditions, or need costly care, we may see our local services unable to provide us with the care we need. Quality of care may be compromised.

Allyson Pollock, Professor at the Centre for International Public Health Policy at Edinburgh University (2006) has indicated that cuts, closures, sale of land and buildings are now proving necessary to balance the books. With gaps in service provision, we may see some private companies bidding to open hospitals of their own, which will inevitably mean that care may no longer be free at the point of access.

If this is true for us, then it will also be true for the people we serve, some of whom are already facing disadvantage which is connected with poorer health.

How could this affect us professionally?

Pay Reforms the NHS cannot afford

For many clinical and counselling psychologists working in the NHS, the words Agenda for Change strike an unhealthy chord. Whilst the principles of equal pay for work of equal value are laudable, the lack of extra funding to support pay reform has thrown the NHS into disarray.

It has created unhelpful divisions between professional groups, and has exacerbated pre existing financial difficulties which are actually based on changes in the health economy, and new rules on financial accounting. The time and energy that many professionals have spent on Agenda for Change seems to have had rather a distracting effect; changes to services are happening apace in many Trusts. Some Trusts simply cannot afford Agenda for Change, and are cutting back on posts. With such a critical financial situation, there are reports of psychology being seen as an 'expensive' option, and earmarked for cutbacks.


Service and job losses

As psychologists we are concerned with mental health, but these services are facing clear and immediate threats, despite Lord Layard's recommendations to expand access to psychological treatments. The Sainsbury Centre for Mental Health (SCMH) published a report in July, highlighting how nearly two thirds of mental health trusts have been asked to cut their budgets, in order to cover deficits elsewhere in the health economy. There are also expected reductions in mental health funding, with trusts only expecting a 3.6% increase in funds. The Sainsbury report found that 63% of trusts surveyed had to reduce their average spending by 3.2% of their budget in 2006-2007. This doesn't leave much cash to spare…

The union, AMICUS, conducted a survey which showed that 71% of trusts were in deficit, with 56% trusts proposing service cuts, and 43% proposing job losses. There are reports of closures to eating disorders, acute wards, and job losses for child psychologists, community teams and addictions teams. Adult specialist posts are under threat. There are reports of fixed term contracts not being renewed, frozen posts being lost and posts not being replaced after staff leave or retire (Waterworth, 2006).

Examples of cuts to service are many. Rethink, the mental health charity, published a report in May, detailing a catalogue of cutbacks. It makes sober reading. In Hertfordshire, there has been an 11% cut in psychological services, disproportionate to cuts to other local services in the area. Here, it has meant the loss of acute beds, a day unit, the early intervention service and job losses across community teams, psychology, older adults and learning disabilities. In Watford, a psychological service for clients was closed, despite clients being part way through therapy. The report indicates many areas where mental health services are being lost, and also specific examples of losses to psychology.

Newer examples of proposed losses to psychology jobs are now emerging. In Northamptonshire, a decision was taken on 13th October, 2006 to close the entire out patient psychology service. In Oxfordshire, there are proposals to radically reduce senior clinical psychology posts, in order to expand lower graded jobs. Less qualified people are being expected to deliver high levels of face to face contact, with clients who have complex problems.

These are examples of what seems to be a national trend in mental health services. The change is unfolding fast, and affecting many parts of general and specialist NHS services.


Weakening Psychology as a Profession?

The Guardian (2005) highlighted how mental health could expect a new age of better resources, in order to address the estimated £25 billion per year that mental ill health costs the UK economy. One of Lord Layard's recommendations was to strengthen the numbers of clinical psychologists in training.

However, stories about losses to established psychology services are being reported, but there is also evidence that newly qualified clinicians are unable to find jobs in their local area. Other professional groups, such as physiotherapists, occupational therapists and nurses are also reporting similar problems for newly qualified staff getting jobs.

With a job market populated by newly qualified staff, or staff made redundant from NHS posts, people may not be in the position to argue for better terms and conditions of employment. The shift towards Foundation Trusts will mean that these organisations can set their own terms and conditions, including pay. This could mean that Agenda for Change reforms are discarded.

The knock on effect could mean that a pool of lower graded, lower paid jobs are on offer. Cheaper staffing options, such as Mental Health Graduates and STaR workers, may be more attractive for cash strapped organisations. Such workers may be expected to take on roles that are beyond their training. Qualified psychologists may be forced to take on downgraded jobs, and this has ramifications for the strength of the profession. With fewer psychologists in post, there are less potential supervisors for trainees. Working in down graded posts could see the profession having to sacrifice other skills, such as research, consultation and teaching.

Psychologists are skilled people with transferable skills, and problems in the health service could impact on morale and job satisfaction. Could we see many qualified psychologists leaving the NHS and moving into private practice, leaving a diminished NHS?


What can you do about it?

As I write this, I am aware that this sounds gloomy and depressing, at a time when there is so much in the news that is also Gloomy and Depressing.

However, I am keen to end on a note of optimism and hope. The NHS was founded on principles of social justice. It has been described as the ultimate in good will whip rounds. We all pay into it, to help out whoever might need it when unwell. Its establishment ended an era of fragmented and inequitable health care. Its birth allowed specialist services and innovation to flourish. It has provided healthcare and jobs for many since 1948. It is, in short, a valued and valuable institution.

If you are concerned by the points raised in this article, then there is something you can do to help. It is imperative that people raise concerns, rather than remaining silent. Think about sparing some time to do one or more of the following:

•    Use your division to raise concerns within the Society. You can find the names of Chairs for each division from the BPS offices.

•    Join the multi union campaign Keep Our NHS Public at www.keepournhspublic.com and find out whether there is a local campaign in your area.

•    Consider whether your local service can work with user groups to lobby against service and job losses.

•    Write to your local MP, highlighting your concerns about what is happening to the NHS. The more mail that your local MP receives, the more they need to address what is happening with the health service. Individual letters have a greater impact than from organisations.

•    If you read an article in the paper about the NHS, then give feedback by writing to the Editor to say whether you agree. Writing letters to the media is a great way of raising awareness about what is happening.

•    Talk to your family, friends, neighbours, colleagues, the person who delivers your post, hairdresser, cleaner…whoever! Explain what is happening in the NHS, and if they are concerned about it, encourage them to contact their local MP, newspaper, radio station, etc

The more the issue is raised, the more debate there will be about the future of our Health Service. And transparent debate about such massive reforms can only be for the good.

References:

Brindle, D. (11 May 2005) Mental Health: an 'Unfinished Revolution'. The Guardian

Pollock, A (1 May 2006) The Politics Column. New Statesman.

Rethink (2006) A Cut Too Far. Rethink: London.

Sainsbury Centre for Mental Health (2006) Under pressure: the finances of mental health trusts. SCMH: London

Waterworth, C (2006) Mind over money. AMICUS Health, issue 3, pp.16-19

Khadj Rouf,  2006.

The author wishes to reiterate that the views expressed in this article are her own. Publication does not constitute endorsement by the Society.

Khadj Rouf is a Consultant Clinical Psychologist working in Oxfordshire in Adult Mental Health. She is also a workplace rep for the union, AMICUS, who represent psychologists. Email [email protected]