“Under this new bill the “duty to provide” will be passed on to unaccountable “clinical commissioning groups”. What does “unaccountable” mean? It means that we don’t vote them in, and, correspondingly, we can’t vote them out. That’s the trouble with taking roles away from elected officials and passing them on to unelected groups.”

Like, say…. Primary Care Trusts?

http://en.wikipedia.org/wiki/NHS_primary_care_trust

The only change happening here is that one type of unelected body is replacing a different type of unelected body.

“Not people who can be held responsible for their actions and brought to a court of law if need be.”

Nonsense. Being a member of a consortia or PCT is not an exemption from the rules of law.

“But at the end of the day, Mr Andrew Lansley had to be voted in by the citizens of this country before he was given this “duty”. And we know his name. He is a real person, alive and everything.”

But you didn’t vote him in to his position as Health Secretary, which somewhat nullifies your point.

[deleted for posting off-topic comment. Please stick to the subject]

[1] so if PCTs and consortia are indistinguishable – why bother to change the system?

Poor old Andrew forgot to tell the electorate (in the tories pre-election manifesto) about his plan for yet more NHS reform – even though Dave C said their would be no more top down meddling, and the cost of it exceeded £3 billion.

If you can’t see this bill for what it is – the doorway to full blown privatisation, then perhaps you need to dig a little deeper to appreciate the tories, sorry coalition’s true intentions.

Of course you may welcome the demise of the NHS – even so it would have been nice for Dave & Nick to put this question to the millions of people who use it rather than forcing through an unwanted bill that has been rejected by the RCN, BMA or indeed anybody who thinks that patients are more important than lining the pockets of the fat cats.

A & E

> so if PCTs and consortia are indistinguishable – why bother to change the system?

It’s not that they are indistinguishable – that’s a strawman.

It is that the premise that the new arrangements are of concern because they are different to the old (are ‘unelected clinical commissioning groups’ ) is flawed because the old system of PCT was the same as the new : ie unelected.

Mary’s article is based on nothing.

“so if PCTs and consortia are indistinguishable – why bother to change the system?”

They’re not indistinguishable universally, but on the claims made by the OP the “lack of accountability” already exists.

[5] John Lister provides a very interesting analysis of the bill – with regard to GP consortia he says this “GP consortia are not required by the Bill even to have a board structure, to meet in public, or to publish any board papers: nor are they even required to cooperate with their neighbouring consortia, or to consult on their plans”.

These arrangements are quite different to those of PCTs.

Lee Griffin I don’t understand your point.

Primary Care Trusts never had a duty to provide health services. The article is quite clearly about the change from the accountable secretary of state having the duty to unaccountable commissioning bodies having it. Something that before was accountable is becoming unaccountable.

Why did you feel it was relevant to mention that there were already some unaccountable bodies in the NHS?

6. I’m afraid Schedule 2, part 1, 4 (c) of the bill shows that despite the arrangements being very different in terms of process and constitution, the level of transparency is required.

Basically, think of the PCT as a small business tasked with running health services…and then think of commissioning consortia as charities tasked with running health services. That’s the level of difference involved.

“Why did you feel it was relevant to mention that there were already some unaccountable bodies in the NHS?”

Because the article is about accountability.

[8] “Basically, think of the PCT as a small business tasked with running health services…and then think of commissioning consortia as charities tasked with running health services. That’s the level of difference involved” – your analysis is far too superficial.

The level of accountability in the post ‘Health & Social Care Bill’ environment has been considered by authors from the Kings fund.

They claim Although GP consortia will be responsible for £60 billion of public money, their governance arrangements are weak, with only limited requirements for how they should be constituted and made accountable to the public.
New health and wellbeing boards – which will bring together local authorities and GP consortia to join up health with other local services – have very limited powers to hold GP consortia to account.
With mixed evidence so far about the performance of hospital boards, the scaling back of Monitor’s oversight of foundation trusts could leave accountability in the hospital sector significantly weakened.

On the basis of the report, which is published at the conclusion of the ‘pause’ in the passage of the Health and Social Care Bill, The King’s Fund is calling for changes to improve accountability under the reformed health system.

Sorry let me clarify… PCTs currently do have legally delegated powers of duty to provide. I only learned of the legal side of this today.

http://www.scribd.com/doc/63555659/Duty-to-Provide-legal-review-NHS-health-and-social-care-bill

Their powers are secured by SI, the NHS (Functions Of Strategic Health Authorities and Primary CareTrusts and Administrative Arrangements (England)) Regulations 2002.

So in practice the Secretary of state already “gave away” this duty.

The key thing here is also that the secretary of state retains the right to change the direction of the consortia if he or she so wishes, so while consortia aren’t accountable as such to the secretary of state, the secretary of state can mandate they do something differently to how they are currently doing it.

“They claim Although GP consortia will be responsible for £60 billion of public money, their governance arrangements are weak”

They are legislatively weak, yes. The reason for this is, like charities (hence why my analysis isn’t superficial), they are given the freedom to come up with governance structures that suit them and work for them.

“New health and wellbeing boards – which will bring together local authorities and GP consortia to join up health with other local services – have very limited powers to hold GP consortia to account.”

For a start, health and wellbeing boards aren’t regulatory so of course they won’t hold them to account. The commissioning board that is appointed by the secretary of state has that job of holding the consortia to account.

The Consortia have to be transparent about these structures and also have direct and involved oversight by a member that is accountable to the board (that is accountable to the secretary of state), and the board has the power to dissolve that consortium if it is not operating properly.

“The King’s Fund is calling for changes to improve accountability under the reformed health system.”

I’m not arguing that this shouldn’t be done…what I’m arguing is that PCTs weren’t accountable either to the general public, so you’re not losing anything here.

I have to ask… have you read the bill yourself, given how much misinformation is flying around?

[11] “The key thing here is also that the secretary of state retains the right to change the direction of the consortia if he or she so wishes” – the very nature of the secretary of state’s role will also be different under the proposed bill.

The wording National Health Service Act 1948 began, “It shall be the duty of the Minister of Health (hereafter in this Act referred to as ‘the Minister’) to promote the establishment in England and Wales of a comprehensive health service.

Again in the National Health Service Act 1977 it ays “It is the Secretary of State’s duty to continue the promotion in England and Wales of a comprehensive health service”.

But in the new bill the Secretary of State
(a) has the public health functions conferred by this Act, and
(b) in exercising functions in relation to a body mentioned in subsection (2A), must ACT WITH A VIEW to securing the provision of services for the purposes of the health service in accordance with this Act.

To quote Dr No, “In the previous wordings, the compulsion created by the must was to ‘provide (services etc)’. In the proposed amendment, the compulsion created by the must is to ‘act (with a view etc)’. At a stroke, the Secretary of State’s duty to provide services has been transformed into a duty to ‘act with a view’ – and ‘acting with a view’ is most certainly not the same thing as providing a service. The ministerial duty has been removed”.

Nobody is suggesting that there will be no accountability amongst consortia but an environment is being fashioned that will foster a system driven by the needs of the consortia rather than the needs of patients.

In the 1948 and 1977 National Health Service Acts, the minister’s duty was to provide a “comprehensive” service, whatever “comprehensive” might mean. It is now proposed that the minister’s duty is to “act with a view” to provide services.

I think that the proposed wording is more realistic about the role of health minister, but if you want the old definition, you are welcome to it. It won’t make a blind bit of difference about health care provision.

[14] “It won’t make a blind bit of difference about health care provision” – so why switch to such weasel form of wording?

If it’s not the secretary of state’s responsibility then whose it (since the SoS merely has to “act with a view”).

You might be nonplussed by this change in wording – but other see it as yet further evidence of the intention to shift the responsibility of providing health care from the state to the boardroom?

By the way a German company (Helios) has been in talks to take over NHS hospitals, the first tangible evidence that foreign multinationals will be able to run state-owned acute services.

“You might be nonplussed by this change in wording – but other see it as yet further evidence of the intention to shift the responsibility of providing health care from the state to the boardroom?”

PCTs were evidence of that, but more importantly… where the boardroom is responsible to the state…what does it matter?

For those who are interested in this, here’s Shirley Williams’s for comment is free, on how the reform threatens the NHS:
http://www.guardian.co.uk/commentisfree/2011/sep/04/nhs-health-bill-andrew-lansley

And here’s the campaign by 38 degrees, busting some legal myths about the reform bill:
http://blog.38degrees.org.uk/2011/09/02/nhs-legal-opinion-respond-to-your-mp/

The UK is only matched by Cuba in its monolithic National approach . It was not what Bevan wanted and it was not especially wanted by any electorate.In any case with its year on year losses of productivity, and worsening inequality of provision what has this supposed accountability achieved but failure ?
The supposed bang per buck of the NHS which looks pretty good except when you can compare (eg on cancer), is only achieved by ignoring the vast black hole in the NHS pension fund. This was £60 Billion a few years ago when the entire FTSE 100 could manage only £20 billion ( coincidentally the amount of savings that they need to find despite astonishingly generous treatment )
Some interesting stats I came across were that only 2 in 5 Nurses would consent to be treated in the hospital they work in. What do they know ? The average number of sick days taken per year is 12 . During the Labour period 85p in the pound of investment was spent in Labour areas …to no good effect .
The Kings fund who note the internationally poor performance of the NHS, have been critically supportive of reform. In the last briefing they applaud a sector specific economic regulator etc. and stuff about integration …. and then I fell asleep but nothing to frighten the horses too much by the look of it . The inference that 100% provision is at risk is , quite obviously a ludicrous scare story .

I suppose this is implication here , if it means anything at all ?

Ha ha .. so that’s what 38 degrees is the start of an avalanche . Well why is it the entire world has not suffered this avalanche then ? What about that ferociously heartless capitalist hell France with its multiple providers insurance top ups and devolved procurement
It must be a mile under the snow with Denmark and Germany and Italy and Australia and absolutely everyone except Cuba with whom we ski happily atop the powdery white stuff. I bet back the 40s old biddy Williams is saying its all ideologically driven ..as if our current ultra planned Nationalised behemoth was not the product of ideology.

I wonder who pays for 38 degrees …..unions ? Anyone know ?

@18 – Do you have any idea how embarrassing it is to be treated by people you know?

(I did volunteer work as a teen, and at 18 had appendicitis. I knew some of the nurses on the ward…VERY!)

“During the Labour period 85p in the pound of investment was spent in Labour areas …to no good effect.”

Ah yes. Such poor effect that the Tories are doing much better, borrowing is down and we’re growing. Wait, what? Oh, right. No, 100% provision is DEAD AND GONE the day this bill passes.

And yes, everyone can know where the 38 degrees funding comes from.

http://38degrees.org.uk/pages/donations-to-38-degrees

So, where does the funding for the “Taxpayer’s” Alliance come from, Paul?

Lee Griffin

Thanks for pointing out that PCTs had the duty delegated to them: I didn’t know that. I’m not convinced that this fact makes much difference though.

If I understood correctly, you think that although the bill removes the secretary of state’s duty, this change makes little difference in practice due to the duty having been delegated to PCTs. However that view doesn’t seem to be consistent with the document you linked to. it’s first sentences are

“It is clear that the drafters of the Health and Social Care Bill intend that the functions of the Secretary of State in relation to the NHS in England are to be greatly curtailed. The most striking example of this is the loss of the duty to provide services…”

Unless you think this expert, who presumably was aware of what he or she wrote about delegation in the very next line, is incorrect I don’t see how you can disagree with the main point of the original article: this aspect of the bill makes the NHS less democratically accountable. Please explain.

I agree, Teddy, that the secretary of state is losing a great legal obligation. I agree with the legal advice wording that you quote above too.

However I think that the whole issue is one that isn’t quite as dramatic as is being made out.

The government is essentially devolving operational level power to of provision to local areas, but not complete strategic direction. You might not agree that this is a good idea, I’m not personally sold on the proposals being necessary, though nor am I sold on the mantra that a devolved system of care provision is evil either.

The practicalities are very little different to the current situation of PCTs, the secretary of state is an overseer while operational bodies make the decisions to run their local health services.

Theonly difference now, really, is that in the past the secretary of state could pull those powers back if they wanted to, for whatever reason, now they can’t.

The reason for this is fairly simple…it’s to give these bodies freedom to work without fear that a change in minister/government will suddenly remove their autonomy. Imagine, if you will, the idea that Scotland could suddenly lose it’s autonomy over night, and how ridiculous that would be.

So instead of the current system we have autonomous consortia, that are able to make their own governance structure (ala charities) within certain frameworks of oversight (certain requirements of membership, appointments and requirements of reports are set out). A national board is created that is the direct overseer of these bodies, with specific powers to stop consortia where they are failing in their duty…and the board itself is appointed by the secretary of state.

Is this functionally any different to the situation of democratic accountability we have right now? I don’t see how. The secretary of state is not democratically accountable to anyone anyway, nor are any of the current bodies providing health services. We can vote out the parties, and they can change direction…but then is that something that should be applauded anyway?

I like the idea of a body being constant amongst various political changes. From an objective point of view healthcare provision, if centered (as this bill attempts to do) around the requirements of patients in the consortia’s area, having an operational body that is constant despite the back and forth of modern politics throwing things in to chaos could actually be extremely beneficial.

This last year has had a lot of blow-harding about democracy, accountability, but in terms that aren’t helpful.

Like the police and crime commissioner debate before…sometimes it’s not the right thing to expect people to be accountable to the public, sometimes it is absolutely the right thing for there to be enough checks and balances in a system overseen by a body that the public do vote for (in this case the government) under a robust legal architecture, that a body can operate without public interference (though not without public input/consultation).

I think the issue of “democratic accountability” is a misnomer in this debate. The issues we need to be wary of are about where provision is sourced from, about how we stop ourselves from being able to go down a route where we doom ourselves to higher healthcare costs because we lose expertise in the public sector… These issues can be tackled whether the legal duty lies with one person appointed by a prime minister, or a whole bunch of people in a devolved structure. In essence, what the OP complains about here is a red herring, it’s only an issue if OTHER issues aren’t dealt with or properly bolted down.

At the end of the day even if the consortia model wasn’t adopted, if the willpower of parliament was to go down the privatisation route that could be done even with the duty to provide being held by the secretary of state. Some may argue that by devolving responsibility the government has made it less likely that the entire NHS will get privatised any time soon.

@23 – Sure, so when it lapses, what do the government have to do and say?

“Oops”, perhaps? Even if he’s engineered the board membership? You can’t even sue him to follow the law when it’s not his responsibility!

There are new layers of bureaucracy, profits to be taken out of healthcare budgets and massive overheads for competition law to be factored in, too. Of *course* being effectively able to drop what he picks of coverage the day the bill’s signed will help make up for those…

Anybody interested in the sort of system that will emerge once consortia are running the show (and for consortia read business interest) might want to have a look at this?
http://www.nytimes.com/2010/08/07/health/07patients.html?_r=1

The process of covertly de-nationalising health services seems to be as follows;
Pivatisation of structure (PFI’s – outsourcing, etc).
Privatisation of services (ISTCs – out of hours P care – Helios, et al).

The next bit, one the dust settles on structure and service privatisation will be to privatise funding – in other words the public will start paying directly to obtain health care.

It hardly needs Einstein to work out that those with the most watertight health insurance policies (for this read the rich) will avail themselves of the sexiest and most cutting edge health care – the rest of us will just have look back thinking, ‘didn’t we used to have a national health service’ based on clinical need (rather than ability to pay) reasonably comprehensive, and free at the point of delivery.

Incidentally a recent study (conducted by the Royal Society of Medicine) found “In cost-effective terms, i.e. economic input versus clinical output, the USA healthcare system was one of the least cost-effective in reducing mortality rates whereas the UK was one of the most cost- effective over the period”.

I can believe that given the charges of £5k to stitch a child’s chin (see link above). According to the Gruniard The “surprising” findings show the NHS saving more lives for each pound spent as a proportion of national wealth than any other country apart from Ireland over 25 years. Among the 17 countries considered, the United States healthcare system was among the least efficient and effective. Researchers said that this contradicted assertions by the health secretary, Andrew Lansley, that the NHS needed competition and choice to become more efficient.

[18] Paul – even the most cursory analysis of OECD stats will tell you that the NHS lags way behind France, Germany, Switzerland and certainly the USA when it comes to funding – and has done for 50 years.

Do you have a view on this humungus cumulative difference? – and in what way will the health of the nation be improved by rewarding the consortia fat cats or introducing opaque health insurance policies – the next inevitable phase on the road to full blown privatisation.

Don’t bank on the secretary of state helping you – if Lansley gets his way the SoS will merely be required to “act with a view”.
“Act with a view” – the sort of gibberish we can expect once direct responsibility to provide health care is abolished.

Perhaps the next time somebody is having a heart attack A&E staff should “act with a view” to doing something about it?

A and E Nurse – Yes but we do not lag behind in the funding of Cancer Treatment where we spend more and achieve worse results than comparable countries .
In other words we only get value for money if you do not account for ill health and remember we live in a country where the male life expectancy of a manual worker is about 72 ( from memory) which is almost identical to the black US population commonly portrayed as being allowed to drop dead in the street unless they bought insurance.
The Kings Fund specifically drew attention to the worsening inequality of health results in the UK as a debit ( although they do point at many positive chnages as well )
You are right of course that total US funding far exceeds ours but then the gulf in results is also huge where it can be measured .
The upcoming spend is about £100 billion ring fenced and thereby putting pressurre on welfare budgets University fees child benefit et al we are spending 50% and a bit every year of GDP and collecting about 38%in revenue , it is hopeless to forget that backdrop

Can I say btw that it is exceedingly frustarting to have this whole conversation warped by pretedning that the choices before us either Soviet Style Britain or the US both of which are highly exceptional. The sort of reforms being suggested have more in common with France Germany Australia in fact ” The rest of the world ” most of which ranks above us on WHO ratings

I would also point out that those spreading this ludicrous untruth are generally recipients of the current final salary related pensions scheme guaranteed job and unaccountable mess we endure . Can you explain the vast rise in managerila staff uneder New Lavbour or the way above norm pay rises ?

How does that contriburte to anyone`s health ?

“You can’t even sue him to follow the law when it’s not his responsibility!”

Yeah, you’d sue those actually making the decisions with the legal duty…so?

[27] “Yes but we do not lag behind in the funding of Cancer Treatment where we spend more and achieve worse results than comparable countries” – cancer accounts for over 200 diseases – you might as well use a term infection.
Which cancer?
Which country are you comparing the NHS to?
And for which time period?

In my book you have couched your cancer claim in Lanselyeque terms even though Lansley has already been bitch slapped by Ben Goldacre (a number of times) for his tenuous ability to understand, or at least accurately report various research findings.

You say “you are right of course that total US funding far exceeds ours but then the gulf in results is also huge where it can be measured” – what does this mean, I mean which measurable results are you referring to – there are numerous papers highlighting the iniquitous aspects of the American system – a country that spends almost twice as much as the NHS yet still fails to provide a system based on clinical need rather than ability to pay.

You (mistakenly) refer to the NHS as a soviet style system – yet as far as I recall the Soviets did not use private finance initiatives to build hospitals, or develop independent sector treatment centres, or privatise out-of-hours GP care, or outsource the majority ancillary hospital services to private providers (cleaning, laundry, meals, etc).

You conclude, triumphantly, that NHS workers are blinded to the truth by mouth watering pension schemes, yet the likes of the BMA, RCN,, or in fact anybody who has spent 5 minutes in a hospital and doesn’t stand to personally gain from the new markets are universally against Lansley’s fatally flawed bill – hell, even the likes of Shirley Williams has been railing against a secretary of state who merely has to “act with a view”.

A and E Nurse
The US survival rate for Cancer is 66.3% , male and UK 44.8% male based on 2000 to 2002 disagnosesas published in the Lancet Oncologogy .Dr. Franko Berrino comented , at the time of the study he lead that ” Survival rates have only improved at a similiar rate to other countries and not caught uopn in absolute terms “.Other comparisons, Germany 50% Iceland 57.7.%
Yes you can break it down , for example in lung cancer we are shockingly bad where our rate of 8.4 % is half that of Iceland and equivalent with Poland despite tripling their spending
Now you say opinion is united but in 2007 Hospital Doctor did a survey in which 43% of Doctors expresed their intention to vote Conservatuve as opposed to 7% Labour reflcecting a dissatisfaction with New Labour`s status quo one assumes
The BMA and RCN are of course concerned legitmately that reform is likely to impact on their members .The reforms include £20 billion of efficiencies now how do you think that will be achieved and what do you think competition does to costs ..ie salaries
I have no special problem with that although it is not fair btw that the private sector takes all the hits , but the views of Turketys on Christmas are not a mystery and not interesting
I think the Kings Fund takes a balanced view and i recommend you read their study on poor English Cancer Survival artes and the latest review of legislation.
In 2009 in the midst of a desperate need for cuts the NHS took on 12% more managers ( Simon Jenkins )

Justify that …

@30 – Now break those US results down more.

Oh look, the rich survive lots, and the poor just die. Great system you’re praising there!

“The reforms include £20 billion of efficiencies”

80% of which end up coming from the front lines because of the efforts being put into another top-down reformation, rather than the 30-40% which would have otherwise been possible.

And no, there’s NOT a desperate need for cuts, there’s a desperate need for spending. Flatline isn’t low enough an economic result for you, is it…

The NHS is not being cut the problem is the increasing demands made on it due to demographic change mean that it has to be more efficient to stand still.
Your suggestion that we are underborrowed ..is …how shall I put this kindly …

Sweet ?

[30] ‘survival rates’ may say more about statistical methods than your chances of surviving a given cancer dependent on treatment offered by the NHS or a hospital in the States.
A man with lung cancer may APPEAR to ‘survive’ longer if detection is recorded at an earlier stage – let’s try a travel metaphor to explain – a train journey from Liverpool to London will always remain 200 miles (say) but the traveling time may be longer or shorter depending on which station you board the train.

You don’t say how much longer the Americans live with lung cancer – days, weeks, months? – a few extra months with extensive metastatic disease may be a mixed blessing for some.

And what about complete remission rates? – in other words cure rates comparing Americans with NHS patients?

In any event the statistical period you highlight (2000-2002) would have still seen the NHS trying to shrug off nearly two decades of tory underfunding, and even though America spent nearly twice the % of GDP on health it still needed a statistical mirage to suggest any benefit.

Before banging the drum for treatment of lung cancer in the states you might want to look at “Insurance Status and Disparities in Lung Cancer Practices and Outcomes.” – don’t forget around 20% of adults in the United States younger than 65 are uninsured.

A study, conducted by the Oregon Health & Science University Knight Cancer Institute, found that Medicaid recipients had a higher incidence of lung cancer and the disease was typically caught at a later stage. Their survival rates, even when adjusted for their stage of cancer at the time of diagnosis, were lower than those with private insurance or Medicare. They also were less likely to have surgery or receive radiation therapy. In fact, the study found that patients on Medicaid were the most likely to die the same month they received their diagnosis. They also were less likely to be treated at major health-care centers, which typically have more experience with the disease.

@32 – “Your suggestion that we are underborrowed ..is …how shall I put this kindly”

No government in Belgium (literally) managed 0.7% GDP growth in Q2. Your kind of policies are worse than none at all. Also literally.

[4] “It is that the premise that the new arrangements are of concern because they are different to the old (are ‘unelected clinical commissioning groups’ ) is flawed because the old system of PCT was the same as the new : ie unelected” – no, that’s not what is being said, JV – accountability is not a synonym for election.

One of the reasons consortia may be less accountable (in the real world rather than on paper) is because of the corrupting effect of money making.

I found this item criticising abuse of PFI arrangements – a harbinger of things to come, perhaps?
http://www.unison.org.uk/acrobat/b681.pdf

Now in theory PFI deals may nominally be ‘accountable’ but this accountability is easily transcended by clever money makers.

It is claimed (above link) that “Accountancy firms have ‘stitched up’ the Private Finance Initiative. They help devise and develop government policy by providing secondees and sitting on government working groups. They recommend which tender to accept on individual contracts. They advise bidders. In their own names they tender for and win contracts. They sponsor projects pushing for more use of PFI and PPPs (Public Private Partnerships). They advise foreign governments on the use of PPPs. And they produce supposedly independent reports claiming that the PFI reduces public sector costs. The result of this cosy PFI circle for the big firms is that they each earn millions of pounds every year in fees. And they stand to earn millions more as the PFI model is sold into more countries worldwide – with the encouragement of the UK Government and the European Union” – “Other ‘big winners’ from PFI include the investment banks, whose role inpromoting PFI and PPPs is just as dubious as that of the accountancy firms. Investment banks invested heavily in Partnerships UK, a joint venture with the Treasury and the Scottish Executive which pushes for more PPP schemes to be established. Facilities management companies Serco, Jarvis and Group 4 are other shareholders in Partnerships UK and also earn massive income from PFI and PPP contracts”.

NuLabour reduced accountability in the NHS however this lot are going to bulldoze it into the scrapheap. Its a characteristic of the US system that it is accountable to profit and the market rather than people. NuLabour should strengthen its attack . The Lib Dems should become far less co-operative. This is preparation for privatisation.