The
Reforms
With the formation of a coalition
government after the 2010 elections, the Conservatives immediately moved to
make good on their promise to pass reforms to the National Health Service. The
Cameron-Clegg government hailed these proposed reforms as “the most radical
shake-up of the NHS since it was formed more than 60 years ago” (Macdonald,
2011). The opposition could do nothing but watch as the Tory-led government
made numerous changes to the NHS.
At the heart of these reforms is the
abolition of Primary Care Trusts (PCTs) and Strategic Health Authorities (SHAs),
which had previously been the main funding vehicle and intermediaries between
the government and doctors. In place of these trusts are so-called “pathfinder”
consortia, which are essentially a pooling of resources by General
Practitioners (GPs) who in turn “purchase” care for their patients. In order to
hold these pathfinder consortia to account, an independent NHS Board was
created to ensure that all pathfinder consortia-provided care meets certain
minimum standards. Proponents of these reforms assert that the changes give
more say over patient care to the patients themselves by cutting out the
middlemen of the trusts and Health Authorities. Opponents of these reforms argue
that the reforms amount to a “slippery slope” that will lead to the full
privatization of the NHS, and also less accountability for the use of NHS
funds.
The nature of the British parliamentary
system allows any party or coalition thereof with a majority of Members of
Parliament to pass their legislative agenda without regard for the minority
party/parties. However, any coalition government must negotiate with its
coalition partners at the formation of said government, and agree to which
legislative items are to be on or off the agenda. At the formation of the Tory-Liberal Democrat
coalition government, the LibDems “pledge[d] to implement most of the ideas the
Tories developed in opposition, such as a new independent NHS board… and
letting patients rate their quality of hospital care” (Campbell, 2010). Although
the Tories made some small concessions during government formation
negotiations, the heart of their proposed reforms were backed by a majority of
MPs. Due to the nature of the British system, this meant in effect that the
majority could pass their NHS reforms at will; barring massive defections, in
which case the government would likely have collapsed. The opposition being in
the minority in parliament have no legislative mechanisms for obstructing the
will of the majority, save using the media to try and sway public opinion.
And use the platform of the media the
opposition did. The Labour Party relentlessly criticized the Tories’ reforms.
As the 2015 elections approached the criticism became more intense. Shadow
Health Secretary Andy Burnham said that “Labour warned David Cameron that his
reorganisation would damage the NHS” and promising that voters “will remember
patients, nurses, doctors and midwives lining up in their thousands and
pleading with the Government to call it off. But they ploughed on and plunged
the NHS into the chaos we see today” (LabourList, 2015). In response to the Tories’ reforms, Labour
responded with a promise to create an NHS “for the twenty-first century”. Labour promised to create such a system by
expanding funding for providing care, and adding thousands of new doctors and
nurses in order to expand access and lower wait times for care.
Background
The
National Health Service was created in the aftermath of World War Two, and has
attained a position in the British psyche that will make any efforts at
privatization sure to stir up a hornet’s nest of opposition. The UK is
currently holding an election and most voters when asked who they trust to
protect the NHS, the majority answer: Labour. This has become a perennial
campaign issue in the UK, with the Tories highlighting flaws in the system in
order to further their agenda, and Labour making unrealistic spending promises
in order to further their own.
The National Health Service is a massive
governmental organization that is the largest such organization in the world
(excluding militaries). Although there
are many who wish to see the service reformed, there are many that view the
service as a national treasure, and therefore something which should be
preserved in its current form. The Conservatives have consistently called for
reforms to the service (read privatization), but have been unable and/or
unwilling to date to implement major reforms. It is my contention, however,
that even if the Tories had a majority in the parliament that the popularity of
the NHS creates informal institutional constraints would limit their efforts
regardless.
Due to the fact that the NHS is such a
popular institution, the Conservatives must be wary of any potential backlash
that may arise as a result of a perceived overreach concerning privatization.
In fact, recent polling featured in Financial
Times showed that a majority of voters, both Labour and Conservative,
support the idea of raising the income tax by 1% or more in order to shore up
the finances of the NHS and avoid any cuts to services (Neville, 2015). Such polling suggests that the Tories must
tread lightly as they continue to pursue their reforms, and will likely seek
incremental implementation of their reforms in order to avoid the perception of
sweeping and radical changes.
The
Process
As stated previously, by nature of the
British parliamentary system, any governing majority may pass its preferred
legislation at will, without regard to the concerns of the opposition party.
There is only one “veto gate” which must be opened in order to pass and enact
legislation. The Cameron-Clegg government, by virtue of being a coalition
necessitated the involvement of multiple “veto players” however. Therefore, Nick Clegg and the Liberal
Democrats were in a position of great strength when they came to the
governmental-formation negotiations to discuss policy concessions and issues
that would be “off the table”. Had the LibDems so wished, they could have
blocked NHS reforms from the outset. But this was the first time the LibDems
had any real power, and they had a different set of priorities. The LibDems
were able to negotiate overall funding increases for the NHS in exchange for
their acquiescence in regards to the abolition of the PCTs and SHAs.
The Labour Party, although furious at the
prospect of partial privatization of the NHS, were unable to halt the passage
of such reforms as they were in the minority in parliament. Labour, long seen
as the “protector” of the National Health Service, campaigned on the issue
relentlessly. This constant attention seems to have had some of its intended
effect, because at the time of the 2015 election a plurality of British voters
named the NHS as their most important campaign issue.
The Tories were criticized by some medical
interests, as well as by Labour for their conduct in devising and implementing
NHS reforms. This is because PM Cameron created a panel of medical interests to
advise him on the issue of NHS reforms, but groups that were seen as critical
of privatization were excluded. This led to claims of cronyism and a lack of
transparency by the Labour Party. Although no such consultation was required
under the British system, it is an informal institutional constraint that all
interested parties to such legislation would be party to such an advisory
panel.
Although the governing majority may pass
its preferred legislation at will, any perceived legislative overreach is
likely to lead to a backlash from the electorate. In First-Past-The-Post
electoral systems, such as the one in England, “what swings one way, can swing
the other” (Shugart, 2015). Therefore, the Tories are unlikely to undertake any
reforms that could be perceived as “extreme” or “radical”. Instead, the Tories
will likely to continue their policy of incremental privatization, rather than
push for full or total privatization of the NHS.
Results
For the fiscal year 2014, the United
Kingdom spent £6.5 billion on private-sector care for patients (Triggle, 2015).
This amounts to a meager 6.1% of the total budget for the NHS. However, this
figure was up from 2.8% in 2006-7. In a classic case of equivalence framing,
the Tories highlighted the 6.1% figure, claiming that their reforms have had
only a small effect on the NHS as a whole, whereas Labour decried the “more
than 200% increase in privatisation”. Regardless of one’s ideological bent, the
fact of the matter is that government spending on private-sector care has
increased as a result of reforms.
In response to these reforms, new
opposition groups were formed. One such group, the National Health Action Party
(NEAP), formed in 2012, has been fiercely critical of the reforms to the NHS. One
of their chief criticisms of the private practices is that these companies can
which procedures that they are willing to take, and that this puts the NHS at a
disadvantage. According to NEAP spokesperson Dr. Louise Irvine, “[t]he problem
is that private companies can cherry-pick what they want to do. They naturally
do the easy stuff, leaving the NHS with the more complicated elements that are
more expensive. That can cause real problems (Triggle, 2015).
Conclusions
The issue of the NHS and its possible
reform will remain contentious for the foreseeable future. However, without the
moderating effect of the Liberal Democrats as coalition partners, the Tories
are likely to further advance their preferred reforms. Having a majority in a
parliamentary system is much more advantageous for a party, rather than relying
on coalition partners which increase the number of veto players. David William
Donald Cameron, having won a majority in parliament with 37% of the vote
nationally, is claiming his victory as a “mandate” by the British people to
advance the Conservatives’ agenda. One must assume that this includes the issue
of NHS privatization, as it was consistently ranked as the number one issue for
voters during the election.
The
Labour Party, having performed poorly in the most recent election, is left
again to watch as the Tories make their preferred changes to the NHS. As a
consequence of having a First-Past-The-Post electoral system the Tories were
able to secure a parliamentary majority on only 37% of the vote. With the
opposition in disarray, and free from the constraints of coalition bargaining,
the Cameron government may continue to implement privatization reforms to the
NHS system unencumbered.
As the Tories move forward however, they
could be side-tracked by the issue of having a referendum on the UK’s status as
a member of the European Union. Cameron has promised to conduct such a
referendum by 2017, at which time the British people will ultimately make the
decision. With such a monumental choice before the country, and with the
ever-growing issue of Scottish independence and the rise of the Scottish
National Party, the issue of NHS reform could easily end up taking a back seat
to issues that are seen as more pressing and/or significant.
Again, because the British parliamentary
system allows the majority to pass legislation at will it would seem that the
Tories could pass whatever NHS reforms they wish; but due to the informal
constraints of the popularity of the program, the risk of being perceived as
radical, and the brutal consequences of the FPTP electoral system Cameron and
the Tories are likely to tread lightly and seek incremental reform. Also, due
to the fact that attention and agenda space are scarce resources like any
other, there is a danger that other issues will come to dominate the Conservatives’
agenda. Especially considering that a referendum on EU membership is such a
major topic of concern that one can easily see it coming to dominate the
agenda.
Until the Labour Party finds a solution to
their electoral ills, the Tories will continue to be able to implement reforms
to the NHS, which, to Labour are tantamount to embarking upon the road to full
privatization. The Tories, on the other hand, need only worry about defections
from its own members. And unless there are massive defections, not only on
legislation, but to the point of its members switching parties, which is highly
unlikely, the Tories will have the next five years to implement more
privatization reforms. As Jonathan Shapiro points out in the journal Clinical Medicine, that the Tories’
reforms have had consequence on the system as a whole, including “an inexorable
move towards increasing specialization” by health care providers (Shapiro,
2013). And as the BBC’s Nick Triggle says “[t]he words privatisation and NHS
together are enough to start a fight in an empty room”, and we can expect to
see the issue remaining contentious for the foreseeable future (Triggle, 2015).
Bibliography:
Campbell, Denis. Coalition agreement - the full deal
at a glance. The Telegraph. May 20, 2010.
Legrand,
Julian. Cameron’s NHS reform is no health
revolution. Financial Times. January 19 2011 16:30
Macdonald,
Victoria. The NHS reforms and you.BBC4
News. January 17, 2011.
Neville, Sarah. Voters back tax rise to fund NHS, poll shows.
Financial Times. April 11, 2015.
NHS “reform” in England: where is the
public interest? BMJ 2012; 344 doi:
http://dx.doi.org/10.1136/bmj.e2014 (Published 14 March 2012)
Shapiro,
Jonathan. Future of the NHS. Clinical Medicine 2013, Vol 13, No 4: 374–7
Shugart,
Matthew. Lecture. POL140B. University of California, Davis. Spring Quarter
2015.
Triggle,
Nick. NHS privatisation: Why the fuss?.
BBC News. 20 February 2015.
Wilkinson,
Emma. The NHS: what are the UK's
political parties promising? The Lancet. Volume 385. Issue 9973, 1059 –
1062.