Britain - NHS free-for-all... for healthcare capitalists, that is!

Jan/Feb 2006

Blair's Secretary for Health, Patricia Hewitt, claims that Labour's planned 10-year reform programme for the NHS is on track. Everything should be in place by 2008, for a "patient-led NHS", with "patient choice", "money following the patient", and "diverse" provision of care, from both the public and the "independent" sectors.

Sure, the NHS is right on track - for private business. Opportunities in the "healthcare market" are ever-increasing under ex-Department of Trade and Industry minister Hewitt. The promotion of profiteering is right up her street.

But for patients, the situation is not looking so good. The total number on hospital waiting lists still hovers around 800,000, which is not all that much less than the 1m in 1997, before Labour came into power. True, instead of waiting up to 2 years, patients can now expect to be seen within 6 months, or that was supposed to be the "target wait" by December 2005. But to achieve such targets, hospitals have merely refused to add more patients to their lists, thus creating another, unofficial waiting list, for the waiting list! And this is hardly surprising, when hospitals have not had their capacity to take more patients boosted significantly and when most hospitals built under PFI actually have 30% fewer beds than the hospitals they replace.

Anyway, patient waiting lists are just one symptom of an NHS which is not meeting need. Behind the NHS managers' habit of massaging their figures, to show that "targets" have been hit, lies a growing shortage of funds across the whole NHS.

Every day a new scandal is exposed, be it the refusal by a hospital to provide a new cancer treatment like Herceptin for breast cancer, on cost grounds, or the sudden denial of a common procedure on the NHS, like the regulation of the heartbeat (which Tony Blair had last year), also on the grounds of cost. Then there is the ongoing saga of dirty hospitals and new "super-bugs" which seems unrelenting, or the figures showing unprecedented increases in sexually transmitted diseases while facilities and staff to screen and treat patients remain woefully inadequate. In fact these are just a few, out of a multitude of signs and symptoms which point to the government's serious NHS policy deficit.

The working class, whose national insurance contributions fund most of the NHS bill, is nevertheless supposed to believe health minister Hewitt's claim that all is well and that the NHS is improving. Far be it from any health secretary to admit that the government's main priority is, and has been, to improve the NHS as a milchcow for private companies who wish to register nice fat profits. The NHS is far too much of a vote winner - or vote loser for that. Blair's government intends to try to keep the wool over people's eyes for as long as possible with its fairytale that the interest of patients is at the centre of its "reforms".

The NHS hot potato may burn Labour's hands

The "free at the point of use" NHS was - and remains - probably the most important domestic political issue for a majority of the British electorate. Nearly everyone, across the whole of British society, needs to use it, even the most determined member of middle England's "anti-state brigade". It is also through this 60-year old institution, the symbol of Britain's "welfare state", that everyone has a chance to judge government policy - on the basis of personal experience.

When the Labour government first introduced its 10-year NHS plan, in the form of a White Paper at the end of 1997, Blair wrote in the foreword, "one of the main reasons people elected a Labour government on May 1st was their concern that the NHS was failing them and their families".

For once he was not lying. And in 1997, there were high expectations that the rot in the NHS would be stopped and that the Tory "reforms", i.e. cuts and insidious privatisation, would be reversed by his government.

Of course, from the very moment Blair took over from the Tories in 1997, he indicated very clearly what his intentions were, with regard to the public sector in general and the NHS in particular.

One of his first commitments was to stick to the Tories' plan to freeze all public expenditure until 1999. Never mind the fact that this was in the context of an NHS in a state of near meltdown, with hospital waiting lists of over one million, dire shortages of staff, rock bottom morale, crumbling and filthy buildings, etc., etc...

But even then, after playing for time for 2 years, Blair's intention was to continue the policies already put in place by its predecessors, although he certainly had to repackage them.

In fact Blair's willingness to continue "Tory" public sector policy was one of the main reasons he had been granted the confidence of the City and the right-wing media moguls in the 1997 election - a confidence which was reaffirmed in 2001 and again, albeit slightly less enthusiastically, in 2005. It was obvious that by 1997, the Tories had run out of steam and lost too much credit to get away with continuing their private interest-led public sector "reform programme".

Of course, "reform" in this respect always meant expenditure cuts, but at the same time and most importantly, more diversion of public money to the capitalists, directly, by allowing private take-overs and profit-making out of public services and indirectly, by enabling the award of tax cuts.

As far as the prime movers in the business world were concerned, the only way the British working class would continue to swallow the deleterious change in social provisions which were the sure-as-hell consequence, was for the "reform" to be implemented by a new, Labour, government.

Now, after 8 years, it evidently remains Blair's assumption that voters, when it comes to the NHS, will still trust a Labour government more than a Tory government. This illusion may well not be something Blair can count on for much longer, however.

Especially so, after David Cameron, the new Tory leader, has made such an effort to appear more socially-minded than Blair on health matters, which is not too difficult, of course!

He has relaunched the Tories' NHS policy as one which acknowledges the NHS as the country's most important and needed institution. "I want to leave no-one in any doubt whatsoever about how we feel about the NHS today. We believe in it. We want to improve it." The Tories will no longer be encouraging people to "go private" by offering them a voucher to help pay towards private treatment. No, they will ensure that the NHS remains "free at the point of need" and "publicly funded".

Of course, the truth is, that this makes Cameron's and Blair's policy pretty much identical. And of course, the issue was, in fact, never whether the NHS would remain "publicly funded" or not. What is at issue, is who gets these public funds, and for what ends. Blair and Cameron are both completely in favour of helping private individuals and companies make a profit out of public health and therefore, in effect, allowing less public money to go towards "national health".

Capital-led reforms

Actually, it was the Tories who first came up with the idea of covering up their cutting and privatising policies with the slogan of a "patient-led NHS".

Having cut hospitals to the bone, the Tories lectured everyone on the importance of "prevention" rather than "cure" just as Patricia Hewitt sanctimoniously does today.

"Primary care", that is, the first line care offered by GPs and community was to be considered the most important part of the NHS. Thus was published, in 1994, by Major's Tory government the pamphlet, "Towards a primary care led NHS", which advocated GP-led purchasing of all hospital and community care services, with health authorities gradually withdrawing from these functions.

GPs were first pressurised into cutting costs, by rationing prescriptions and even by throwing "expensive" patients off their lists. They were then offered financial autonomy through becoming "fundholders". But not all GPs wanted to go down this road and the Tories cautiously avoided pushing things much further.

So when Labour took over in 1997, it was up to Blair and health minister Frank Dobson to do the pushing. The policy was duly repackaged and extended. Health Authorities were abolished and "Primary Care Groups", later to become "Primary Care Trusts" (PCTs), were created, which in effect, organised all GPs into collective fund-holding and took over the planning of local healthcare and its provision.

GPs and local community health and social care are today all under the roof of around 300 of these Primary Care Trusts (PCTs), which theoretically administer 75-80% of the NHS budget, by providing local healthcare and "purchasing" specialist diagnosis and treatment for their patients from hospitals.

But the "reforms" are by no means over. In July last year, Sir Nigel Crisp, the NHS chief executive, published a document called "Commissioning a patient-led NHS" to reform PCTs yet further, by 2008. This was obviously a cost-cutting exercise, since they would be reduced in number mainly via mergers from 303 to 144 and they should no longer provide community health services themselves, thus threatening up to 250,000 NHS primary care jobs with "privatisation" and/or eradication.

Alternative "independent" providers are meant to be established to take over these services. The government argues that provision of community healthcare can be "more efficiently" provided by the so-called "independent sector", including private companies, of course.

PCTs will have the job of creating the space for these by withdrawing the existing contracts for locally provided services from NHS clinics and GP health centres. But strangely enough, the Department of Health itself intends to take over the job of "awarding" contracts to the "independent providers", rather than allowing the PCTs to do this, while at the same time arguing that the reason for all these changes is to bring all the local players closer to each other!

This has already caused uproar among GPs and NHS staff involved in providing local "out of hospital" healthcare. In East Oxfordshire, where these changes were already being "piloted" by an overzealous Strategic Health Authority, the Department of Health has called a halt to further implementation. Likewise. it has had to reinstate a consultation period (14 weeks) over all of its planned "out of hospital care" changes from mid-December 2005.

It remains to be seen what final shape Labour's "primary-care-led" NHS will take. But Patricia Hewitt has recently given a fairly explicit idea of what the government aims for.

She told the following story during the "Annual health and social care lecture" at the London School of Economics on 10 December: "some weeks ago, I met the social entrepreneurs, Jo Prichard and Tricia McGregor who, with the support of their PCT are leading the creation of Central Surrey Health, a not-for-profit co-operative that would be owned by over 700 district nurses and other community staff to provide care within the NHS. They are clear that by combining the freedom and flexibility of an employee-owned organisation with the values of the NHS, they can match the care they give far more effectively to the personal needs of their users. I want to see more NHS social enterprises and in the new year I will be announcing how in health care, we can build upon the work of the social enterprise unit that I created at the Department of Trade and Industry."

What a "social-sounding" myth! But a myth nonetheless. For the watchword of these "social entrepreneurs" will be, of necessity, "efficiency" - or in DTI-speak, "value for money". If they are less "social" and more "entrepreneur", they might survive, but not by providing what patients require, in fact. If they have a conscience and try to provide a good service with the time and resources needed for patients, they are likely to go under and then possibly be bought by one or other "for profit" private healthcare consortium, which have access to much larger sources of funding.

This is what happened in dozens of cases when privatisation of the buses, railways, and ancillary functions in local government and the NHS took place. Ex-employees often formed companies and bid to supply the privatised services. But they got swallowed up by bigger fish. Thus small bus companies soon "merged" into today's giants like Stagecoach, small cleaning companies became part of Rentokil or Serco and small IT concerns part of Capita or IBM. The cynical Hewitt knows this better than anyone else.

This January, Labour will be publishing a new White Paper on community health care, laying out the "next steps". There is still a lot of space for private companies to occupy, after all!

The Tories' foundation for "payment by results"

"Payment by results", that is, money following the patient to whichever healthcare provider is "chosen", was also an idea first expressed by the Tories in the 1990s under John Major's government.

The introduction of the "internal market" in 1991 laid the foundation for it. "Supply and demand" were supposed to act by themselves to reconfigure the NHS. Central planning was out!

In effect, this market just split the NHS into two halves, with purchasers on the one side, that is, GPs and community health "buying" of medical treatments on behalf of their patients, and hospitals as the "providers", doing the "selling".

Hospitals - renamed trusts - would start to behave just like private companies, with their own budgets and the requirement to balance their books. For some time already they had been expected to seek ways of generating part of their own funding through selling land and buildings, renting out space to commercial enterprises (like WH Smith and MacDonalds), contracting out services, charging patients for TV and telephones, turning their parking lots into profitable enterprises, etc., etc. But of course, most of their income came from contracts from their GP "purchasers" in the community, who also were expected to balance their books.

However, all of this did not and could not create a real health "market". The new NHS managers who had been seduced into hospitals from the business-world by giving them titles like "chief executive" and paying them huge salaries, soon found that transposing methods from Sainsbury supermarket did not work very well either. The NHS was a public service where the "customers" did not pay and where the cuts, on top of chronic historical under-funding, placed severe limits on hospitals which were trying to "compete" on "price". As a result they failed to function properly and in fact soon got into serious trouble.

"Choice", which was supposed to be the engine of inter-hospital competition, was only possible if the hospitals were within a prescribed distance from the patients needing them, anyway. Hospital managers found themselves in a catch 22 as far as cutting their charges were concerned (to get the edge on their competitors), because this actually meant cutting staff and therefore cutting the service they could offer. It also meant not meeting the "performance targets" which had been brought in so that hospitals could be judged against each other. So waiting lists mounted. Supply could not meet demand.

Another reason that the crisis of supply developed by 1997, was that there was still no substantial private health care sector in place yet, to provide the capacity which had been cut out of the NHS. It would take Blair to "develop" this!

Nor could the Tories find a way to justify the initial increase in public investment required to reduce the risk for private companies to embark on the Tory-proposed PFI projects, in order to build new facilities or rebuild old ones. Again, that was something Labour would sort out.

But over their 18 years in government the Tories nevertheless managed to lay all of the foundations for today's NHS.

Labour's success for the City

Blair's tasks were threefold: find a way for the "market" to work, make PFI attractive and create space for a significant private health sector.

On all these counts, Labour has had some success, from the point of view of the City, not of patients, of course!

To all intents and purposes, its main achievement has been to put some order into the chaotic health "market" created by the Tories. Just as in the capitalist economy as a whole, state intervention is usually a way of cleaning up the capitalists' mess for their own benefit. This is what Blair did in the NHS.

Despite claims that the internal market has been "abolished", it has remained in place. Only for the time being, it has been "regulated" by fixing the prices for procedures, appointments, operations etc., across the whole country, thereby turning the NHS into some kind of nightmarish "Kwikfit" for the human body, which is, in fact far too complex for such a framework. But this has allowed NHS trust hospitals to once more have their departments up and running, sometimes to capacity.

However, the element of competition between trusts, in areas like London, where there are lots of alternative hospitals for GPs to "choose" from, still makes planning capacity to fit "demand" a bit of a gamble. And while (for the moment) hospitals do not compete anymore on the actual price of the service they supply, they are still expected to make efficiencies in order to "balance their books", by saving on other expenditure, be it medical staff, drugs, equipment, or cleaning...

For Blair to make PFI "attractive" to the private sector, however, there was no option but to increase funding for the NHS substantially. But even the City now took this for granted. Why should it demur, if it was going to have so much of this new NHS investment channelled straight into its coffers?

Indeed, the Labour-revamped PFI and PPP projects, to build or rebuild hospitals or instal new equipment, were very lucrative for the private sharks - at least initially. At huge cost to the taxpayer, (at least £18.3bn since 1997), this funding, which has often been way above initial estimates has lined the pockets of construction companies, banks, insurance companies, private healthcare companies, the IT industry, lawyers, management consultants and many others, for the past 10 years. And public money will be filling the pockets of the main players for a long time to come, since the yield from the "interest", charges, management fees and lease-back agreements, is usually payable for 25-40 years.

It was somewhat inevitable that this particular shark feast would have to end at some point. In fact today, some planned projects which have not yet been started, are now being put into question by the Department of Health on the grounds of "affordability". Construction group, Skanska, which was due to benefit from a new £1.1bn rebuild of Barts hospital in east London may now lose out, due to "unexpected" escalating costs. The building of the new St Mary's hospital in Paddington which had already cost £14m in the planning stage, was recently cancelled - the excuse being that it had been "misconceived". To justify further possible project cancellation, Patricia Hewitt has used the argument that since the NHS is meant to be led by primary care, "monster hospitals" are no longer in keeping with today's needs.

This flies in the face of fact. If the poor, as she admitted in her recent lecture at the LSE, are most likely to fall ill, why even think of cancelling the rebuilding of a hospital serving the east of London, where some of the most deprived families in the whole region live?

The money pumped "into the NHS" by Blair's governments since 1999 has been unprecedented, even if most of it has not gone on healthcare. In cash terms, the government really has "doubled spending on the NHS" since it came into office, in the sense that in 1997, NHS spending was around £45bn, whereas in 2005 it was around £87bn - or so Brown claims.

However, as a percentage of total government spending, the increase in health spending is only 3% over the past 6 years, an increase from 14.3% in 1999 to 17.3% in 2005.

What is more, health spending is already being cut. Over the next two years, the government tells us it is spending £135bn, and boasts that this will mean another "one third increase". Yes, this may well mean such an increase over the average spending over the past 8 years. But actually it means a cut in funding compared to 2005, of £45bn in cash terms over two years!

Blair prefers to compare his spending on the NHS with the "European average" expressed in proportion to total GDP. And from 5.7% of GDP in 2000, spending is meant to have increased to 9.4% (the European average) of GDP by 2008.

But even health economists and academics who are largely sympathetic to the government's NHS policy, like the Reform group, are sounding warnings already, because the government's figures do not add up.

If most of the plans for the following period are implemented, the NHS budget looks as if it will register a £7bn shortfall by 2010, at the very least. Reform explicitly says that "efficiency" savings (cuts) have to finance any improvements if trusts are to balance their books. No wonder large capital projects are being put into question. But what else will go to the wall?

Already 20-25% of NHS trusts - 29 acute hospitals and 23 PCTs - have registered a deficit for this financial year to a total of between £640m and £1bn.

The official reason for this current deficit out of the 2005 budget of £87bn was that part of it went on one-off "hidden costs", due to new contracts for staff, pension transfers and so on.

However, what also emerged is that only 2.4% of this huge and unprecedented annual budget has been spent on new beds!

So where did all the money go? The answer to this question is the answer to the question of "who benefits?" from today's NHS, and whose actually interests lead it.

The truth is that the bulk of this £87bn went towards paying for accumulated commitments to private companies via PFI and PPP. "Efficiency savings" are not just a future scenario, but already had to be made last year to pay for any improvements, or so-called "additional activity". And in fact for any future NHS expansion, a choice will present itself, but not the one Hewitt boasts about. Hospitals will have to cut existing services to offer any new ones.

The d-efficiency agenda

The Department of Health's (DoH) unofficial "secret memo" exposed by the Observer in December 2005, to freeze all spending immediately and stop all new recruitment throughout the NHS, is probably official policy, in fact.

Of course, the accusation levelled at the 52 over-spending trusts is one of "bad management". But for the DoH, all this means is a management which does not make enough cuts in order for its books to balance. And if the trusts in deficit should be nominated for "failing hospital" status, what should happen to them? Should they close down, to make way for private alternatives, or be taken over by the private sector?

The DoH financial "hit squads" which have been sent in to the over-spending trusts have been told to implement £200m of cuts immediately, to reduce the overall deficit before the end of the financial year in April 2006.

It just so happens that nursing staff shortages are a main source of "overspending" because agency staff are engaged, systematically, at higher cost. How it is possible that there are still shortages of nurses, we have no way of knowing, when government targets for nurse recruitment have, according to DoH figures, been exceeded! 40,000 more nurses were needed by 2005, and nearly 70,000 were already in place by 2004. Hospitals still find themselves short, even at this "excess" level. Talk about figures not adding up!

Anyway, the DoH has announced that in the offending trusts, no doubt the most hit by shortages of nurses, their remedy is going to be to "save money" by slashing 5,000 to 6,000 jobs, including 1,200 nurses!

It turns out that the trusts which have admitted to deficits so far, are just the tip of the iceberg, since many trusts use all kinds of accounting ruses to disguise their deficits, for instance by deferring certain mandatory spending until the next financial year. After all, a whole layer of "market-minded" managers on market salaries were recruited to run NHS Trusts, and it is only logical that they should resort to the same age-old tricks used by bosses in the private sector to massage their balance sheets.

Anyhow, it seems that all trusts, as well as the flagship Foundation Hospitals (of which there are now 32) will be making cuts in the near future if they are to "balance their books".

So what will happen to the "record" number of NHS staff who have apparently helped this government to turn the health system around? The general view of "independent" experts is that too many staff have been recruited and too many new staff are being trained! Patients on waiting lists of six months will be surprised to hear this, as will the huge number of victims of hospital-acquired infections or their surviving relatives.

By 2010 there will be 42% more graduating doctors than this year. But now the experts are throwing up their hands in horror. To quote Reform: "In a situation where there can be little expansion in capacity this must mean substantial medical unemployment. There is already some evidence that NHS trusts are having to cut back services and in the worst cases cutting the number of staff. New medical graduates are already facing serious obstacles to getting jobs. While the government claims that this is not a widespread problem and that most graduates have posts, a survey by the BMA in July 2005 found that 38% of graduates had not been offered a post to start in August 2005 while 87% expressed concern about the availability of training posts within medicine."

Why is the NHS in a situation where there can be little expansion in capacity? Is this not what one million patients still waiting for hospital beds, needed urgently, yesterday? What was the point of investment if not expansion? But horror of all horrors, it turns out that on the contrary, the NHS is contracting, that is, getting smaller!

And one has to wonder what will happen to all the newly recruited NHS staff who have been helping to get the NHS back onto its feet again - more or less? Will "reasons" be found by Home Secretary Charles Clarke, to send those who were head-hunted abroad, back to where they came from?

Naturally, it would be far too much to expect for the DoH to create more additional posts so that the NHS really could expand and improve the "quality" of the "service" it "delivers"!

No, apparently "quality" is meant to improve as a result of introducing increased competition, via what this government calls "patient choice", even if the only criterion by which patients and GPs can compare different "providers", if they exist, is how quickly they offer their service, but not how adequate it is.

Driving in a wedge for the sharks

Behind the government's apparently benign slogan of "patient choice", designed primarily to appeal to the individualism of middle England, lies its far more ominous twin, "payment by results".

This is, of course, the method of allocating NHS funds aimed for by the whole series of reforms since the 1980s.

By referring to it as "payment by results", no doubt middle England is reassured that the tax it pays, at a record low since Labour came in, is nevertheless put to good use.

But what does it really mean for healthcare?

Payment by results is meant to ensure a "patient-led NHS", with "money following the patient". And all the better if this money ends up in the bank account of whichever private healthcare provider "supplies" a consultation, diagnostic procedure like a scan, surgery, or whatever else is required.

In Labour's "abolished" internal market (!), payment by results will force hospital trusts really to "compete" for patients with each other, in order to get their share of state funding. But they will also be competing with private providers. What "payment by results" becomes, is in fact a wedge, driven in by this government on behalf of the private sharks, which will allow them to get a greater share of the day-to-day health budget.

It incorporates "choice", because theoretically a patient will be able to choose between 4 providers of the service he/she needs, one of which will have to be a private one... just to be "fair"!

The "commissioner" of the required procedure will be the GP, and the payment will thus be made from the primary care budget allocated by the government.

Already the advent of a "competitive market" between hospital trusts who provide certain services in a similar or overlapping catchment area, has meant that some are actually under-used, while some are unable to cope with "demand".

So far, the absence of co-ordination as a result of the breaking up of planning in the name of competition, has only resulted in increasing the difficulty for patients in getting treated. But with the advent of "payment by results", whereby hospitals will only get funding for the procedures which they actually carry out, under-used (and stand-by) facilities will be forced to close. This will leave those remaining open even less able to cope with demand. What was so far the result of a lack of proper planning, will become a built-in feature of the NHS.

Payment by results may result in a drastic fall in income for some hospitals, to the point where they are unable to meet standing payments for historical debts, fixed capital assets, PFI, etc., unless the DoH changes the financial rules for NHS trusts. But it may first be prepared to see closures of public facilities, to the advantage of private ones. And what if the privately owned "independent treatment centres" then decide that they no longer wish to accept NHS patients at the NHS fixed tariff? There may be no alternative "free at the point of use" facilities left in a particular locality, because they have previously been forced to shut up shop.

The example of "NHS" dentistry - or what is left of it - should provide ample proof of what eventually happens when "money follows the patient" as a fee-for-item-of-service, especially when, as is the case for dentists, there is so much scope for private practice! Half the population is no longer registered with an NHS dentist, and dental health is at an all-time low. Ironically, the new NHS dental reforms are trying to reverse this state of affairs, in other words stop money from following the patient! So dentists are being put onto salaries, which are no longer linked to how many procedures and treatments they perform. And prices for individual treatments and procedures are being phased out!

Towards a commercially-led NHS

It was the absence of commercial principles which was the main strength of the NHS, even though it was always flawed in many ways, rationed, and always underfunded. But in fact it was one of the "cheapest" health services in the developed world! Its economies of scale, integration at least of its hospital services and its centralisation, allowed it to be remarkably efficient, so that health spending per head of population in Britain remained far lower than the European average and around one third of that of the US for 40 years, if one compares the figures between 1960 and 2000.

This could be taken as a failing. However, if one takes life expectancy at birth or infant mortality as indicators of the NHS "success", these figures show that in Britain people were not all that worse off than their counterparts in Europe and slightly better off than the average US citizen.

We are told the NHS needs "reforming"? Yes, all along during its existence it needed more resources - and it still does. It needed more staff - and it still does. It has always needed GPs and a first line care to be integrated properly into the rest of the NHS - which it never was - so that diagnostic and treatment pathways for patients are free of unnecessary obstacles and delays. But the NHS also needed to get rid of the private parasitism on its facilities not least by pharmaceutical companies. Not to mention the use by hospital consultants of beds for private patients when there were very often not enough beds for NHS patients. Instead, this private parasitism has been entrenched by Blair's policies.

Blair's policy is not, in fact, a "Tory" policy, as such. Like the Tories, Labour has merely implemented the policy dictated by British capitalists by the beginning of the 1980s. While speculation on the world financial market had become their main way of making money, the risks involved were and are, a big problem. A far safer way for them to make money is provided by the state's assets and budgets.

This is why Thatcher and Major opened up the vast coffers of the state in every possible respect to private capital. This is why they made cuts in the public sector and sold off state industry and public utilities and why they introduced the market into the NHS after cutting it down to a skeleton.

But the status of the NHS as the "nation's best-loved institution", means that any government dealing with it, has to operate with caution. The wholesale privatisation of the NHS was not a viable option, because there is always a large number of working people who cannot afford to pay for treatment - who provide cheap labour to the bosses. Keeping the poor healthy enough to work is another (essential) way of subsidising the bosses, after all.

On the other hand, introducing a totally new system of medical insurance, as in France, or even a system like the one in the US, is an option, although the radical changes which such a project would require are a little risky for any British government to embark on, for fear of it back-firing electorally. Unless, of course, NHS hospitals and community services start to disappear and the only facilities which are still available in some areas are private ones. This is precisely what could happen if Labour's reforms are played out to the end.