Bengoa Report: a blue print for privatisation
There is an assumption that the way the only way forward for the health service in Northern Ireland is the implementation of what has become know as the Bengoa report. This is the report by a panel (chaired by Prof Rafael Bengoa) that was appointed by the the then health minister Michelle O’Neill to examine the future of health and social care.
The Bengoa report, published in October 2016, made a number of stark warnings about the state of the health service and put forward a number of recommendations on how it could be improved. Though the theme of the report was ‘Systems, Not Structures’, its major thrust was the restructuring of the health service around what are known as Accountable Care Organisations (ACO’s). They bring together most of a local area's NHS services under a single budget, which is then run directly - by one big organisation (which is the ACO). The role of these organisations is the planning and provision of services to a defined population within a fixed budget. On a regional level the recommendation is for the HSC to take on the role as strategic leader. It would have corporate structure and be headed by a chief executive who would have operational independence. There is also a recommendation n for a longer commissioning cycle. While the report says that “is not about closing hospitals” it goes on to concede that “some buildings/hospitals will close”.
While it is not made explicit (and probably deliberately so) the commendations in the Bengoa report point only in one direction an that is towards greater privatisation. Accountable Care Organisations are vehicles for the outsourcing of services to private companies. As the British Medical Association has warned: "Combining multiple services into one contract risks the potential for non-NHS providers taking over the provision of care for entire health economies." The recommendation to extend the commissioning cycle is to make the health sector more attractive to private finance. While the proposal for operational independence which would remove the leadership of the health service from any public accountability and make them less likely to respond to public outcries
These proposals were endorsed by the Stormont executive. Even during a period when the political institutions were starting to unravel this was one issue on which Sinn Fein and the DUP were in full agreement. In her statement to the Assembly the then health minister Michelle O’Neill went into shock and awe mode declaring the “current model is unsustainable” and that Trusts would have to prove their major services are viable in order to keep them open. She even declared that it was “a fresh start for health” - highlighting (consciously or not) that health care reform was a companion to the austerity programme embedded within the Fresh Start Agreement.
The recommendations of the Bengoa report were hardly surprising given the make up of the panel that drew it up. Rafael Bengoa is closely associated with the promotion of with private finance within health care in his role as vice chair of Horizon 2020 (the EU programmes body tasked with liberalising public services) and also as the Director of the Health Department at the DEUSTO Business School in Spain. Bengoa also advised the Obama Administration on its health care reforms that became the Affordable Care Act. While these reforms were promoted as an extension of health care the main thrust of them was primarily about protecting the insurance industry reducing costs to business. Other Panel members included Doctor Mark Taylor, a local consultant surgeon with major interests in Kingsbridge private hospital and the Ulster Independent Clinic; and Mairead McAlinden, Chief Executive for Torbay and South Devon Foundation Trust, who in 2015 oversaw the 700 job cuts and the closure of 100 acute beds.
In many ways the Bengoa report is a rehash of the earlier Transforming Your Care report. It too was the product of a review panel convened by the then health minister to examine the future of health and social care in Northern Ireland. The thrust of this earlier report was the restructuring of of care provision through the creation of new commissioning bodies and the rationalisation of hospital based acute services. In these reports commissioning is always a mechanism for privatisation - the replacement of direct public provision with services bought in from private providers. Rationalisation is always a cover for cuts. The argument that centralising services is more efficient may make sense at a rhetorical level but when put into practice it always amounts to less that what was before.
Indeed, it is a feature of such reports that the real intent is hidden behind reasonable sounding propositions. It is only when the proposals are put into practice that their true nature is revealed. This was certainly the case with Transforming Your Care whose outworking included the announcements by a number of Health Trusts in early 2013 that they were closing all their NHS care homes. The outcry over the distress caused to elderly residents forced a public u-turn from the Departmental of Health (though the policy of running down public care homes has continued albeit in a less dramatic way).
Despite the presentation there is really nothing new in the Bengoa report. Its primary purpose is political - to repackage and relaunch a health care strategy that had was badly tarnished and discredited. It’s vagueness seems designed to deflect any potential opposition. Not that there was any serious opposition, certainly not on a political level where it received almost unanimous endorsement. The Bengoa report was also welcomed by the trade union movement. NIPSA stated that there were “ elements we can embrace” while Unite declared that it would adopt a “positive outlook towards this process of reform”. This was very much in keeping with ICTU’s endorsement of the Fresh Start Agreement and its programme of austerity.
The consensus across the political parties and the trade unions is that problems within public services can only been addressed through the restoration of the Assembly an the Executive. In the case of health care this means the appointment of a health minister and the implementation of Bengoa. But as a strategy this is certain to end in disappointment - for the record of the previous Stormont administration was poor and the recommendations in the Bengoa report will only serve to deepen the problems within the health service rather than solve them. A former Stormont health minister, Simon Hamilton, has talked about the need for consensus and taking the "politics out of healthcare". But what is really needed to defend the health service is a challenge to that consensus.