Dr John Puntis writes: The founding principles of the NHS have long been under attack, but now it seems that some politicians from both Conservative and Labour parties are predicting its impending collapse unless radically reformed. The latter, of course, involves diverting even more money to health care and insurance companies, and propping up a small, inefficient and often unsafe private sector, famously described by Julian Tudor Hart as ‘the red light district of the medical profession’. The first priority for saving the NHS must be to acknowledge and reverse the catastrophic underfunding that has brought about its decline.
Privatisation is not the answer to the NHS’s problems
A publicly funded, provided and accountable NHS is the fairest and most efficient way of providing good health care to the population, and essential for a productive economy. KONP regards the founding principles of the NHS to be just as relevant today as in 1948. There are those who have long been ideologically opposed to this model, arguing that it has now failed and therefore merits a radical overhaul. The evidence base for this argument is weak, and such calls have been robustly challenged. In fact, a market in healthcare increases the likelihood of inequity and exploitation with suboptimal care for both rich and poor.
Current dire problems in the NHS are clearly linked both to lack of planning particularly in relation to workforce, and chronic underfunding. The Health Foundation has recently estimated that spending on healthcare in the UK lagged behind comparable European countries to the tune of £40bn each year over the decade before the covid pandemic. Some US academics, keen to see a single payer system in their country, have looked at recent pro-market developments in the NHS with a mixture of horror and incredulity, while putting their finger precisely on the motivation – ‘such reforms offer a covert means to redistribute wealth and income in favour of the affluent and powerful’.
It is only a coherent long-term plan to build capacity in the NHS that will solve the current crisis
The government published its elective care recovery plan for dealing with the pandemic backlog in February 2022. It was immediately criticised for absence of a workforce plan and failure to address issues in emergency care, intimately connected with waiting lists. Neither were mental health nor general practice covered despite their considerable difficulties. In fact the plan was focussed on long term reliance on the private sector even though private providers had during the pandemic shown themselves to offer very poor value for money. Block booking of 8000 private beds led to a 25% increase in NHS spending on commissioning while 27 private hospital companies managed to deliver 43% less funded NHS healthcare than they did in the twelve months before the pandemic.
The ‘plan’ effectively institutionalises NHS dependence on costly and inefficient private sector hospitals and beds while recognising that the real problem is in fact lack of adequate NHS capacity. Private hospitals can make more money from self-funding patients than through NHS tariff meaning the NHS is likely to have to pay over the odds, with these same providers standing to benefit from long NHS waiting lists and helping themselves to NHS staff. The delivery plan anticipates that in the long term, the NHS would be confined to a role of providing emergency services, medical care and more costly, complex treatments that the private sector has always avoided.
‘Turbocharging’ – or throwing money at the private sector?
The government has now set up an Elective Recovery Taskforce (‘Government turbocharges efforts to tackle Covid-19 backlogs)’ to help deliver its recovery targets; once again, the major emphasis is on using the independent sector. This approach is problematic not least because the private sector is relatively small (around 8000 beds) and lacks capacity. While more patients who can afford it are turning to independent hospitals, the same hospitals are treating fewer patients under their private medical insurance. Probably as a result of the pandemic, fewer consultants are working in the private sector and most who do so work in the NHS. This means that if a surgeon, for example, does more work in one sector, he/she does less in the other.
Nineteen further community diagnostic centres (CDC) have also been added to the 92 already established, supposedly to deliver more ‘life saving checks, tests and scans and speed up diagnoses for local patients.
Community Diagnostic Centres
CDCs are supposed to separate urgent tests (done in hospital) from non-urgent investigations that can be carried out in a community setting. Whether they have actually moved care closer to home is disputed (many are located in hospitals). They are frequently hyped as ‘life saving’ and were first recommended in 2020. While acknowledging potential benefits of more rapid access to testing, the NHS Confederation pointed out (together with many others): ‘It is vital that we have a sustainable staffing model for these hubs, as well as any new service provision in the future, given critical constraints on the existing NHS workforce’. It is clear that the government has favoured headline-grabbing short-term funding for local partnerships with independent providers, rather than long-term investment in staffing and capital equipment for the public sector.
Meanwhile, one of the flagship CDC partnerships at Somerset Foundation Trust (hailed as “game changing”) came to grief after only eight months when the commercial partner Rutherford Health went into liquidation. The National Audit Office has also pointed out that both CDC and surgical hubs rely on adequate staffing, and key staff could still be diverted to other parts of hospitals at busy times, noting limited evidence of their ability to continue operating when their host hospital or wider local area is under significant pressure.
Chipping away at the NHS as a public service
With underfunding and understaffing now having led to horrendous NHS failings for all to see, despite raised voices clamouring for radical ‘reform’ the massive majority of the public still support its core principles. Pressure has come from right wing think tanks obscurely funded by foreign donors and often given a platform by the BBC. Some prominent politicians use private health care services while other public servants undermine the NHS in different ways. For example, ex-Tory MP Sir David Prior, when chair of the Care Quality Commission, saw fit to call for massive cuts in hospital bed numbers, and for hospitals to be taken over by US healthcare corporations.
Simon Stevens was appointed as chief executive of NHS England, holding the post for seven years having been a leading Blairite special advisor, an unapologetic proponent of competition in the health service, and working nine years at the top of an American health insurance company. According to some, in terms of developing and promoting the central tenets of the NHS – those of universality, equity, and indeed ‘freedom from fear’ – he was as far removed from Aneurin Bevan as you can get.
Many of the proposals in Lansley’s Health and Social Care Bill were drawn up by McKinsey (the leading US Consultancy) and included in the 2012 legislation wholesale. The recent Health and Care Act signposted further fragmentation of the NHS, greater privatisation and damage to services and the workforce. Sunak has appointed Bill Morgan, a private healthcare lobbyist with links to a series of controversial clients to advise him in Downing Street; Morgan was previously a special adviser to Lansley. Patricia Hewitt has been recruited by Jeremy Hunt to advise on health service reform. As Labour Health Secretary in 2005 she set up ‘independent sector treatment centres’, brought in contracts with the private sector for pathology tests, scans and elective surgery, and pressed GP commissioners to outsource services. Allegations over political lobbying saw her suspended from the Labour Party; Wes Streeting expressed delight at her recent appointment.
The All Party Parliamentary Group (APPG) on Health Care Infrastructure explores key challenges facing the buildings, technology and facilities supporting the NHS and has recently published its first report (based on testimony from only a handful of witnesses and written submissions). Although APPGs have no formal parliamentary status, they produce reports that are often endorsed by ministers, and they are commonly advised and even directly managed by private entities. In this case, the APPG is sponsored by four private firms with a financial interest in health infrastructure.
Business (as usual) is the All-party group solution for the NHS
The report notes the huge problems related to massive maintenance backlog, shortage of staff, and lack of funding for new equipment. Commenting on NHSE allocating only 7% of its total expenditure to capital compared with a European average of 10%, rather than concluding more should be spent, it argues that the ambition to meet all health infrastructure needs through public funding is not viable in the current financial situation. Third party development of community facilities is endorsed, citing the NHS LIFT programme involving public private partnerships, and in operation since 2001. Tellingly, there is no comment on the massive burden on the NHS represented by the Private Finance Initiative deals.
In Scotland recently the question of a future two tier health service came out into the open.
Senior health officials said they were given the “green light” to discuss reforms by NHS Scotland chief executive Caroline Lamb. One suggestion in leaked minutes, was to design ‘a two-tier system’ which would see those who could afford to, go private. No doubt such discussions have also been going on in England. Coverage of this story has highlighted that journalists are good at listing the symptoms of the NHS in distress without ever questioning the underlying cause. The public would be served better if they started asking: Why is the NHS in crisis? What is the truth behind the repeated assertion that the NHS is receiving record funding? Why can’t we afford the NHS?
What does Labour say?
The Labour Party has remained relatively silent on the NHS believing that it is trusted by the population to do the right thing. A comprehensive motion was passed by delegates at this year’s party conference, including a position of outright opposition to, and commitment to vote against, any and all forms of privatisation. But this is not binding on the executive and is likely to be ignored, just as was the fate of the 2017 conference motion also calling for reversal of all privatisation. While Labour has made a welcome commitment to increasing staffing, it has given little detail of how it would address underfunding, the crises in mental health services, difficulty accessing urgent care, pressures on GPs and the ongoing toll of Covid 19. Labour’s ten-year plan for the NHS is short on detail and deals with common generalities such as the importance of prevention, access to GPs, and shifting resources from hospitals to social care and community. Such thinking has been central to the NHS over the past decade, but has been ineffective because of lack of funding, lack of the staff to deliver, and a failure to tackle the social determinants of health.
Wes Streeting, the shadow Secretary of State for Health and Social Care, has clarified Labour’s position recently, although his comments will ring alarm bells with NHS campaigners and many members of the public. In a Guardian Opinion Piece, Streeting endorses use of the private sector, saying he does not want those who cannot afford to pay (‘working class people’) to be in pain while waiting for treatment. He also states that ‘Had a Labour government been in office this year, hundreds of thousands more patients would have been treated on the NHS in private hospitals’. Insisting that ‘We cannot continue pouring money into a 20th-century model of care, if we are to meet the challenges of the 21st century’ sounds worryingly like blaming the Bevanite model of care for failure rather than recognising it has been failed by politicians.
Claiming that the NHS must ‘reform or die’ also sounds like a readiness to depart from founding principles, while pointing out the NHS is ‘a service and not a shrine’ borrows directly from disparaging right wing rhetoric that the NHS is treated as a national religion. Perhaps not surprisingly, these perspectives are coupled with reports of a desire to ‘take on the hostile unions holding back the NHS’. David Rowland (Centre for Health and the Public Interest) has pointed out that private hospitals do not spend money on training staff but take them from the NHS, are difficult to hold to account when scandals over patient care arise (such as the rogue breast surgeon Ian Paterson), do not have intensive care facilities so often transfer sick patients to the NHS, and provide poor medical cover, putting patients at risk. In addition, some of the companies involved have been found liable over price fixing and healthcare fraud.
The logic that given its current difficulties the NHS must turn to the private sector suggests lack of any serious long term vision as well as a blindness towards the parasitical nature of private care, and hastens the likelihood of a two tier service being the end result. A major reform of the for-profit sector is long overdue. In the meantime, what about the radical idea of simply requisitioning its beds at the present time (if it is indeed possible to increase capacity) to reduce further pain, suffering, and death? This was the approach taken by the Spanish government when Covid struck (in contrast to the decision in England to rent 8000 beds at £300/day/bed). The UK situation now undoubtedly constitutes another grave emergency, with literally thousands of preventable deaths occurring each month.
Mr Streeting may be correct to say the NHS is no longer the envy of the world, but should reflect that only five years ago, it was rated as top performer among rich countries by the Commonwealth Fund. With sufficient investment it could become so once again, but this will not happen by turning to the imagined ‘spare capacity’ of the private sector and trying to sell this as a progressive policy. To make such promises may be music to the ears of right wing pressure groups like the Policy Exchange, but goes completely against the wishes of many of the Labour Party’s members and the public at large. The current crisis without the right vision and intervention may indeed be existential for the NHS, but it sounds increasingly as if Streeting and former Conservative Secretary of State for Health and Social Care, Sajiv Javid, are singing from the same discredited hymn book. What a tragedy if the party that brought in the NHS proved to be its nemesis.
What should we expect from opposition parties?
Opposition parties should explain clearly to the public that the crisis in the NHS is a consequence of policy decisions made by government. The failure to fund the NHS adequately over the period of a decade has created a situation in which it is now difficult for performance to recover. The public needs to understand why, in the face of ‘record funding’ (untrue), waiting times remain poor and waiting lists continue to grow. The increasing use of public money to contract with the private sector instead of expanding the capacity of the NHS results in drawing staff and funding away from the NHS, progressively weakening it. Cherry picking of patients by the private sector (which is mainly situated in London and the south east) leads to greater inequalities, and increases the proportion of the NHS budget diverted away from health care and channelled into the pockets of shareholders, the directors of private companies and as second salaries or fees to doctors practising privately.
A clear commitment to public provision is essential as is a willingness to improve pay and working conditions and to safeguard professional status, since these are essential for staff morale, for safety and efficiency. The wider determinants of health must be addressed through redistribution of wealth and the reduction of economic inequalities. The shrinkage of the NHS relative to need and unrealistic targets for “efficiencies” among NHS providers must be exposed. Unambiguous commitment to adequate funding, the retention of taxation-based funding and expansion of NHS capacity to reduce waiting times is essential. A sense must be created that the opposition merits election to government on the grounds of vision, values, trustworthiness and ability to implement sound policy
No surprise to campaigners, but excruciatingly embarrassing for the government, a recent report commissioned by the Department of Health and Social Care has just identified a “decade of neglect” by successive Conservative administrations as having weakened the NHS to the point that it will not be able to tackle the 7 million-strong backlog of care.
There is a pressing need for an evidence-based analysis of what service configuration and funding mechanisms for health and care will maximise effectiveness and equity, and be resilient to the challenges posed by this pandemic as well as future shocks. It is vital to involve the public, professionals and politicians in building a consensus around a new vision for health, care and support fit for the pandemic era.
Although the NHS has been battered and fragmented and continues to be under relentless attack, there is still much left to defend. It is estimated currently that around one fifth of the NHS budget flows to the private sector, which means four fifths is still spent on publicly provided services. Whereas the challenge to campaigners is huge, the conclusion by some that the NHS has already been downgraded to an American-style managed care system dominated by private health insurers is surely premature and serves only as a disincentive to fighting back. KONP will not give up the struggle.
Dr John Puntis is co-chair of Keep our NHS Public
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