Nurses for Reform Blog

This is the text of my speech to the retired members and fellows of the Royal College of Obstetricians and Gynaecologists.

Lades and gentlemen, thank you for inviting me here today.

The title of my talk is “why Nurses for Reform do not believe the Government’s health reforms go far enough”.

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Nurses For Reform – or NFR – is a small organisation with only 200 nurses in membership.

It was established by me in 2006, and its objective is to promote genuine free market reforms across healthcare.

From the outset, NFR has been designed to be a low cost, lean and mean, cyber organisation and nurses who sign up, do so, free of charge.

Today, representing very much a minority perspective, we nevertheless attract a growing amount of media attention – and our views are starting to be taken seriously by politicians – across the political spectrum.

NRF regularly appears in the national press and media, and we now enjoy an ever-expanding on-line following.

In the last few weeks alone our views have been reported in The Daily Telegraph, The Guardian and I have been extensively interviewed on the BBC.

And it was not that long ago I spent an hour with David Cameron in his office presenting NFR’s policy ideas for substantive healthcare reform.

If you listen to John Prescott, The Daily Mirror and countless other friends on British the left, then NFR is the free market conspiracy in British healthcare!

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Now, when the NHS was created back in 1948, not only was it established on the basis of taking into public ownership 3,118 independent hospitals and clinics, but, crucially a leaflet was posted through the door of every home in the country.

It contained – in black and white – the promise that was supposed to be full-blown state healthcare… its “founding principles”.

The leaflet stated, and I quote: “[the NHS]…will provide you with all medical, dental and nursing care. Everyone – rich or poor – can use it.”

The key word here was the word all.

The State was going to provide all medical, dental and nursing care.

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Today, sixty three years on, the NHS has never come close to making good this promise.

Indeed, as time passes, UK healthcare is moving ever further away.

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There have always been services that the NHS has never provided.

While at first doctors in NHS hospitals were encouraged to treat patients according to need, within a couple of years of the service having been established they found themselves working under the imposition of cash limits which soon turned them into the politicised allocators of scarce resource.

Soon, the supply of health – and social care – in the UK was rationed by massive queuing.

Crowded waiting rooms became common in most general practices and out-patient departments.

By the late 1960s, queuing had even become a significant factor for in-patients and those waiting for operations and treatments deemed a “priority”.

Indeed, certain health services have never been provided by the state, reducing demand still further.

Much psychiatry, the treatment of infertility and substance misuse are cases in point.

In reality, people have never had a right to free and equal treatment.

What they have had is a right to a promise of being treated at some distant point in the future and without much mention of quality when they actually get there.

It must also be noted that only in theory does the NHS treat everyone equally.

For as Professor Julian Le Grand of the London School of Economics and Tony Blair’s health adviser made clear a few years ago – relative to need – professional and managerial groups have tended to receive more than 40 per cent more NHS spending per illness episode than those in semi- and unskilled jobs.

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Now, in the early years of the NHS, the government made very little investment in its newly acquired health estate.

In fact, during the first decade of the NHS, not a single new hospital was built.

None were even approved until 1956.

And then there was the Great Hospital Plan of 1962!

Even by the mid-1990s most of it had still not even been commenced.

As the health commentator Professor Allyson Pollock pointed out in the middle of the 1990s:

“The plan…remains unfulfilled, with only a third of the projected 224 schemes completed, and a third not yet started.”

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In reality, the government never really did get around to investing on the capital side of the NHS, which is why Prime Ministers such as John Major and Tony Blair turned to private sector capital and expertise under their private finance and public private partnership initiatives.

It is with this background that Blair signed the Concordat with Britain’s private hospitals in 2000 – enabling NHS funded patients to get independent sector care and treatment for the first time.

This is why in 2001, a Labour government wanted a new generation of Independent Sector Treatment Centres.

It is why in 2003, the government tried to push through Independent Foundation Hospitals and wanted them to be able to raise private investment on the open market.

It is why we have the Patient Choice Agenda.

And it is why we now have the Health and Social Care Bill going through Parliament.

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Make no mistake.

The NHS is being redefined and recast.

In the future, the NHS will simply be a funding mechanism but it will not be the owner of the facilities in which people are cared for or treated.

Looking further out, nor will it be the controller or manager of healthcare professionals.

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At this point, I could of course talk about the collapse of NHS dentistry, or the way that spectacles were privatised in the 1980s, or the way that to manage NHS waiting lists the service has become ever more reliant on using capacity in the UK’s 220 independent hospitals…

But alas, I don’t have time for that…

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What I want to do with the time that remains is tell you what I think the Bill going through Parliament is actually about, and why NFR does not think it goes far enough.

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Overall, I am pleased that the government is planning to empower patients by introducing what will in effect be a shadow-voucher system.

For in enabling patients to freely choose their general practitioners and then having the vast majority of the NHS’s funds flow through their hands, the system can move towards a much more open and diverse market in provision and facilities.

In the future, I believe no one in this country should ever have to go into any hospital owned or directed by the state.

Whether for-profit or not-for-profit, mutual, worker co-operative, or charity, all our hospitals, clinics and care homes must be set free from political control and returned to independent forms of ownership.

These organisations should then be free to raise money commercially or as they see fit, and free to reap the rewards of serving patients well.

It is vital that UK hospitals and clinics are freed from the constraining and historic shackles of the Treasury.

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When looking at the current Bill in Parliament, I think it is good that in the future, not only will hospitals be allowed to raise investment and capital from private sources, but that the caps on their private pay-bed work will also be removed.

For too long, high quality independent provision has been the preserve of the well-healed and those able to afford exclusivity.

For too long, private hospitals have profiteered with high margins from the manifest failings of nationalised provision.

However, where Nurses for Reform differs from the government is that we also believe national collective pay bargaining arrangements have run their course and should be abandoned.

Alongside privatizing NHS hospitals, NFR wants the government to encourage a more vibrant and open labour market for the benefit of all doctors, nurses and other health workers.

No one working in healthcare should ever have their professionalism and integrity undermined by uniform, one size fits all, politically decreed, pay scales.

Nor should remuneration be imposed and held back at regional level.

To properly value doctors, nurses and other healthcare professionals, remuneration must be set at realistic levels but this will only happen in a more open, dynamic and responsive market.

Similarly, NFR wants the government to end health censorship.

In today’s internet age it is absurd that advertising by doctors and pharmaceutical companies are still largely restricted or subject to outright bans.

Why can’t GPs advertise and compete with each other?

What can’t Foundation Trusts advertise on television or in local newspapers?

Why can’t many medicines operate under the rubric of commercial free speech?

To encourage informed patients and build trusted brands we must dramatically liberalise the laws surrounding health information: we must encourage a lot more advertising.

While there is no such thing as perfect information or perfect knowledge, better-informed people are able to make choices and better decisions.

Trusted brands can also deliver powerful checks against producer-capture and the monopoly abuses of those with professional – monopoly – legislative favour.

And that means you and the GMC and it means me and the Nursing and Midwifery Council.

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Finally, I think the government should go much further to liberalise the planning laws surrounding the building of new hospitals and all other health and social care facilities.

We need to make it much easier in this country for social enterprises and entrepreneurs to build new healthcare facilities.

Instead of an ever shrinking healthcare estate we need to respond to the demographic and medical challenges of the future by enabling a rich and diverse tapestry of institutional arrangements more focused on consumers, quality and value for money than the politics of greedy vote motivated politicians and trade union leaders.

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To conclude:

NFR is established and we here to stay.

We are small, but we have a distinct voice.

We are free marketeers who put patients and best value above professional and sectional vested interest.

We are not afraid to criticize the state or the NHS.

And we have a clear agenda.

While we think the current Bill before Parliament is at best only an incremental step in the right direction we also think it is a missed opportunity.

From a consumer perspective, it does not go far enough.

What we want is universal independent provision.

We want more healthcare advertising so as to inform and build trust.

We want an end to national collective pay bargaining.

And we want to do away with planning laws that restrict supply and keep prices artificially high.

What I want is better healthcare for all and I want the vote seekers to get out of the way!

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Thank you.

Last Friday I gave the key note speech at a seminar for the retired members and fellows of the Royal College of Obstetricians and Gynaecologists.

This is a very insightful comment from my friend Sam Bowman of the Adam Smith Institute;

“I wonder how many people going to the UK Uncut march today actually realise they’re fighting for the right to pay for the educations of people going to the Boat Race.”

Nurses for Reform are delighted that leading intellectuals in and around the Labour Party are starting to echo our views when it comes to the potential role for mutuals, cooperatives and friendly societies. Criticizing New Labour for being too statist and hinting that trade unions should find refreshed roles as private service providers, this interview with Maurice Glasman in The Guardian is superb.

Come on Maurice and Blue Labour, support NFR’s campaign to have all UK hospitals returned to an open and diverse independent sector. You know that no NHS patient should ever have to go into any nationalised hospital or clinic again. You also know trade unions should be more effective when it comes to offering various forms of private and mutualist healthcare coverage as a benefit of membership.

If only Tony Blair had really pressed ahead with all of this when he was PM.

Yesterday I was on BBC Radio 2’s Jeremy Vine show (from 1:24:30 to 1:31:20) discussing the UK’s Healthcare Reforms.

After a decade of absence from the UK’s healthcare policy debate, the Chief Executives of Britain’s five main private hospital groups are now politically re-engaging. Perhaps concerned by the government’s drive to create independent foundation trusts, encourage lots more private new market entrants, or as the result of a removal of the cap on the amount of private pay bed work formerly nationalised hospitals will be able to do, the key players in the sector are again finding their voice. Robert Wise (the CEO of Spire Healthcare), Adrian Fawcett (the CEO of General Healthcare Group) Michael Neeb (President and CEO of HCA International), David Mobbs (CEO of Nuffield Healthcare) and Jill Watts (CEO of Ramsay Health), have all put their hands in their company wallets to fund the new campaign group: ‘H5 Private Hospitals Alliance’.

Slightly smacking of cartelized corporatism and narrow sectional interest for my taste, Nurses for Reform believe it is a pity that this group currently excludes from membership 20% of the independent sector’s hospitals. Sound charities such as King Edward VII (the hospital used by the Queen and other members of the Royal Family) and The London Clinic have not yet been invited to join. Nor has the blue-collar friendly society and charitable stand-alone hospital, The Benenden, in Kent. The latter alone serves one million Post Office, British Telecom and public sector workers and their families. This is a missed opportunity because Benenden is not only a beacon for David Cameron’s ‘Big Society’ but, formed in 1905, it serves as a vital link to the independent sector’s past prior to the ruinous National Insurance Act of 1911.

Moreover, mindful of what Adam Smith said in his seminal work, The Wealth of Nations (“People of the same trade seldom meet together, even for merriment and diversion, but the conversation ends in a conspiracy against the public, or in some contrivance to raise prices”), NFR believes that political campaigns like H5, backed by businessmen, have to go out of their way to avoid the perception that they are conspiring in some way against the public interest. It is with this in mind that NFR urges H5 to consider the following pressing recommendations:

1. H5 is not a good name and should be changed. Branding that deports narrow vested interest in this way is likely to be distrusted by journalists, officials and politicians.
2. To be sustainable, the group must not be perceived to be the plaything of the five big private hospital groups but instead it should be genuinely open and inclusive of those willing to champion core ‘principles’ such as private enterprise, investment and patient choice. To gain legitimacy and respect, all independent hospitals and private pay bed units should be considered for membership.
3. To capture the moral high ground and coherency of debate, the organisation should proactively campaign for all UK hospitals and clinics to be returned to independent ownership so as to benefit all patients irrespective of their funding streams. In the future, no NHS or privately funded patient should ever go into a hospital owned or run by the state. To promote quality and efficiency, all provision should be returned to independent forms of ownership.
4. The group should join Nurses for Reform and other free market liberals in calling for a dynamic consumer-led market in complementary funding streams. As well has having top-ups, private health cash plans and private medical insurance alongside NHS funding, in the future, all UK hospitals should be free to launch and/or white label their own local community insurance products. The key objective here is to complement core NHS funding with innovative forms of private healthcare, particularly for people on low-incomes (and as is already the case in the education sector with the superb New Model Schools).
5. To promote new forms of private healthcare funding for those on low incomes, the group should campaign for significant supply side reforms. This can include the liberalization of all health advertising (including medicines), so as to empower patients and build trusted brands, and even the ending of national collective pay bargaining for doctors, nurses and other health professionals: so as to create more dynamic, flexible and efficient labour markets.

Following NFR’s recent letter in The Guardian (third one down) and this superb article by Steve Baker MP on Conservative Home, perhaps the greatest challenge for H5’s board will be to recognise there are two types of CEO. There are farmers and hunters. Up until recently it has been the farmers that have arguably led Britain’s private hospital groups. Willing to make a healthy living off the back of a nationalised and failing NHS, they have ploughed their familiar and lucrative furrows over and over again.

However, NFR’s view is that to be a player in the future of healthcare, mere farming will not be enough. The strategy and creative mind of the hunter looking to do things differently is what will matter. What free marketeers and consumers want from people in private enterprise is high quality, cost effective and well-designed products and services, not the old reactive quest for new forms of legislative favour or statutory barriers of entry and exit.

To use a metaphor: Britain’s private hospitals must now be seen to represent the best of Hong Kong and do everything they can to argue for a liberatory end to state-failure and unnecessary suffering in China (NHS socialism). Overtime, this is how the private sector will truly win friends and influence people. The key challenge is not to grubbily ‘protect’ our ‘private hospital Hong Kong’ but to open up China to Hong Kong’s ways. In doing so, Hong Kong’s leading entrepreneurs (our independent healthcare leaders) must firmly fix their strategic gaze on China’s much bigger prize: its awesome potential for growth and the liberation of many millions of its patients – especially the poorest.

So, are Robert Wise, Adrian Fawcett, Michael Neeb, David Mobbs and Jill Watts reactive farmer-protectionists or are they hunters seeking to sow the seeds of a more moral and business-like future for UK healthcare? Nurses for Reform certainly hopes they are growth-seeking hunters on the side of the angels. As free market and entrepreneurial angels ourselves we will certainly do everything we can to encourage and support them. It is with this in mind that the five-points presented above are freely given as serious and helpful recommendations.

H5: welcome back to the world of market liberal campaigning.

Today is National No Smoking Day and true to time-honoured tradition the government have announced that cigarettes and other tobacco products will have to be kept under the counter from 2012 in large stores and 2015 for small shops. The government is also considering even more censorship, possibly via plain packaging for cigarettes.

Away from all the government’s blather concerning enterprise, freedom and personal responsibility, the illiberal jack-boots of the do-gooders are again on the march. But this time the unintended consequences of their actions could well turn out to be demonstrably counterproductive. Indeed, once instituted, these measures will be a bridge too far for even the most ardent enemies of freedom. My guess is they will end up ushering in a world of more smoking via criminality and a vast sea of cheaper, untaxed and illicit tobacco.

Back to the future

Stigmatised, marginalised and treated with no sense of proportionality, British smokers are being reduced to the perilous and irrational status that a number of minorities suffered in Germany around 1934 and 5. Today, 23% of Britain’s are being made to feel guilty for who and what they are and everyone else is being encouraged to ‘un-normalise’ them.

In an over zealous quest for puritanical national-health-hygiene, advertising billboards have already been torn down and are now illegal. Smokers have been forcibly barred from entering many premises (restaurants, pubs, clubs and hospitals etc.,) and they are excluded from all forms of public transport. Even on a long distance twelve-carriage train, there is no room for any degree of tolerance. Forced to pay for this persecution with £5.50 in tax on every £6.50 pack of cigarettes, smokers are now the twenty-first century’s equivalent to yesterday’s racial and sexual minorities. Marginalised, persecuted and exploited smokers are the people many in society now feel comfortable in vilifying.

Time to stand up and be counted

Simultaneously pitied, hated and left out in the cold smokers are the new minority that I believe all health workers should now be protective of. For when a terror starts to strike, it is not good enough to blindly stand by and obey politicians’ orders. While I choose not to be a smoker, I recognise it is time for good people to stand up on the side of common sense, proportionality and basic tolerance. Being a British libertarian who has always hated racism, homophobia and cruelty, I have a keen sense of when things are going too far and when in the name of the public or collective good, persecution is being unacceptably legitimized.

The tide of inevitability is now turning to favour tolerance

Up until now, the greatest weapon in the armory of the intolerant has been their use of the psychology of inevitability. There is no point in resisting their commands because all resistance is futile: the future belongs to the cleansed and the pure – not the smoker.

And yet, slowly but surely, the tide is starting to turn. Devoid of commercial free speech (advertising), a seat on a train, a chair in the corner of a pub, the right to view a packet of fags above a shop counter, or for it to have a distinctive wrapper, the future is now increasingly clear.

As has already happened in Ireland, the sense of inevitability will turn to favour freedom. For there cheap tobacco is now widely available and being successfully marketed by ever more powerful criminal gangs. It is rumoured that the former IRA is a major provider and even counterfeit cigarettes are now thought to be available virtually everywhere in the country. Indeed, in recognition of the unintended horror that has been created, the Irish government is now actively avoiding any tax hikes on cigarettes for fear of making an already dire situation into a total, meltdown disaster.

Thanks to Cameron, Clegg and Lansely’s plans announced today these criminal gangs will now be eyeing up mainland Britain. Through cheap illicit tobacco they will be looking to increase their customer base and ultimately the overall number of people who smoke. Moreover, in time, they will want to spread the habit down the age range to the naive and vulnerable – in particular teenagers and young adults.

If I were a former terrorist or a member of a criminal gang at the cutting edge of Western Europe’s illicit tobacco trade, I think I would now consider ways of not only surreptitiously supporting groups like ASH and the even the public health policies of the Coalition government but I would do anything in my power to try and keep the nanny state’s sense of perpetual advancement entrenched in the UK’s psyche.

Today in Ireland, my nightmare would be that my side starts to lose the long-term sense of inevitability. If I were a die hard Al Capone, I would fear the Irish government taking a more pragmatic and tolerant stance towards tobacco, and the smoker, for if they do this it would put me out of business.

For NFR, the lesson of National No Smoking Day is simple: life is not black and white. As humans we are riven with shades of grey. When it comes to the purveyors of tobacco it is perhaps better to accept the devils we know rather than the ones we don’t. As a non-smoker this is not easy. But as a practical Brit, my nose for commonsense and fair play tells me it will be for the best. Prohibition has never and will never work.

NFR contributes to a letter in today’s Daily Telegraph

Enemies of enterprise seek controls on tobacco

SIR – Today, smokers are asked to observe No Smoking Day. They may also finally get to hear Government proposals that could ban the display of tobacco products in retail outlets, and only allow tobacco to be sold in plain, state-prescribed packaging.

If the Coalition is committed to defeating the enemies of enterprise, as David Cameron, the Prime Minister, claims, a good start would be to call a halt to the relentless campaign to “denormalise” smoking through an endless barrage of new controls, directives and diktats.

Mr Cameron claimed last weekend that he would wage war on bureaucrats who concoct ridiculous rules and regulations. Banning the branding of tobacco products or making cigarettes an under-the-counter product would be yet another victory for these very bureaucrats. Life would become more difficult for newsagents and tobacconists and easier for the providers of illicit tobacco to pass off their wares as legitimate.

We cannot yet be sure about whether the Prime Minister’s commitment to combating regulation and red tape is truly serious. If his Government now unveils proposals to further restrict the sale and purchase of tobacco, it will be a clear sign that his new commitment to enterprise is little more than political rhetoric.

Patrick Basham
Director, Democracy Institute
Dr Eamonn Butler
Director, Adam Smith Institute
Donna Edmunds
Director of Research, Progressive Vision
Dr Helen Evans
Director, Nurses for Reform
Dr Tim Evans
Chairman, Economic Policy Centre
Daniel Hamilton
Director, Big Brother Watch
Angela Harbutt
Executive Director, Liberal Vision
Tim Knox
Acting Director, Centre for Policy Studies
Mark Littlewood
Director General, Institute of Economic Affairs
Matthew Sinclair
Director, The TaxPayers’ Alliance
Simon Richards
Director, The Freedom Association

NFR has a letter in today’s guardian newspaper.

Mark Porter’s claim that the government’s health reforms will take healthcare back to the 1930s is historically inaccurate. By then, local government and charities, not the private or co-operative sectors, ran most hospitals.

As a nurse, I do not believe that any NHS-funded patient should ever have to go into any state-owned hospital or clinic; everyone – rich or poor – should go independent. What we need is a world of provision that echoes that which existed prior to the ruinous National Insurance Act of 1911. We need mutuals, friendly societies, co-operatives, charities and for-profits all providing a diverse tapestry of high-quality healthcare. What most frontline nurses know is that we need to get national and local political ownership out of the system so that doctors, nurses and patients are put back in control. The real tragedy is that the government’s healthcare reforms do not go far enough.

Dr Helen Evans

Director, Nurses for Reform

I find it both amazing and very sad just how many stories there are in the UK press at the moment about the disaster that is NHS cancer care.

Yesterday, the Daily Mail reported that patients are often being sent home with signs of cancer being missed or not followed up.  While today there is a new report out showing that, despite the billions of pounds that have been poured in to the NHS budget in recent years, the UK is amongst the worst countries in Europe for surviving cancer with around 10,000 lives per year being unnecessarily lost.

Just when are our politicians going to wake up and realise what the public already knows?  The NHS is a shambles, people are losing their lives and this system just cannot carry on.