Irwin Brown of the Socialist Health Association wonders at a fragmented future for the NHS

When the previous Tory government came into power in 1979, they had a clear agenda about changes to public services and they had a hidden agenda that allowed them to weaken the likely centres of opposition to their plans.

They used their state power to reduce the power and role of the trade unions and local government, and they used a variety of means, including the break-up of the council estates, to weaken communities. The Labour opposition was poorly placed to oppose.

Education, education, education
This time what is planned, for health is foreshadowed by what is already underway in education. It used to be accepted that the value of education to us all was such that the state should provide it for free - and indeed should offer grants and incentives to allow those from poorer families to take opportunities.

Now whilst primary and secondary education remain free and state-funded, further and higher education have had the funding slashed and increasingly the cost will be borne by the students and their families.

In education organisation, the role of the local education authorities is under attack and soon they will be defunct. No longer will education be under any kind of democratically accountable system: no more planning; no more support; no more intervention when things go wrong.

The huge store of knowledge and experience which resides in the education authorities will be dispersed and wasted.

Every school will be independent, autonomous and isolated, having to buy services in from the private sector. They will be free to vary terms and conditions of employment, and successful schools in affluent areas can attract the best teachers. Parental choice rules, and new schools can open even if there are already surplus places in the area.

Schools will close if their pupil numbers dip. It is a market system, even if price does not yet play a part. If they get into difficulties they will not get help, they will further decline and close. If things are truly awful as happens once or twice every year, nobody can intervene and sort it out, except possibly the Police!

Coming in health
So in health we can see the same themes - but less advanced. The first stage is the transfer of commissioning to GP commissioning consortia, loose federations of small businesses, apparently free from any accountability, certainly with no vestige of the democratic kind. These quangos will spend £80bn of our money!

Almost all of the rest of the latest “reforms” simply flow from this fundamental power shift; PCTs and SHAs are no longer necessary and the DH has to morph into a giant quango so that GP commissioning consortia are not performance-managed in the way the DH / SHAs held PCTs and non-FTs to account.

The kind of vague role defined for local government within all this stops well short of giving our elected representatives proper responsibility for our care, which stays in quango land.

As patients are increasingly given the freedom to choose where they get their care we again see a market developed with patients choices being the only driving force. As choice dominates, planning becomes impossible.

In time, the GP commissioners and the local authority functions will be defunct. Again: no concept of planning to meet local needs through a local strategy; no democratic accountability; no intervention to help those in trouble or to prevent the worst abuses; no guarantee of continuity of services.

New providers can come in and edge out the existing players and services, clinics and even whole hospital will close if they lose some of their patient flow.

Turning all the NHS providers into autonomous, independent organisations of various kinds again moves away from any system of accountability. They will be free to break away from national terms and conditions, greatly reducing trade union power and influence. They will be free to use ex-NHS resources to treat as many private patients as they wish, even if this is to the detriment of NHS patients in the queue.

To prevent the NHS providers working together and forming some effective power groupings, there will be a regulatory system - there only to ensure the maximum competition, quick to step in if providers are seen to collaborate or co-operate as that is anti- competitive.

Patients will choose where and when they go but may have to pay a premium for some services and options: only the basics will be funded by the NHS. User charges which the poor can reclaim will be progressively introduced. And to transfer even more risk from the state to the patient, systems will be brought in to give patient the money deemed appropriate for them to fund their own care and they will be left to make the best of it.

Luckily, the idea of an NHS where patients have freedom to choose from a range of competing providers for every service is likely to be impossible as much specialist and emergency care can never fit into a proper market.

Giving very sick or elderly patients, often with multiple conditions, the money to buy their own care has severe limitations. The GP commissioners may not be daft enough to be used as dupes in the move to a market system.

So maybe the Tories will never get to their 10-year objective, but they will do enormous damage to our NHS on the way.

The first stage of the plan to close down our National Health SERVICE and to replace it with a quasi-market SYSTEM made up of quangos and social enterprises, which can be seen as the step of removing the possible centres of resistance. The end game is a fully privatised market system with a high level of penetration by private providers, where only a basic residual service is free at the point of need.

Nobody ever voted for this change. Just as in 1979 and (arguably) in 2002 the government is changing our NHS without any electoral mandate. Will they get away with it again?