Kailash Chand and Allyson Pollock
(Reproduced with permission: first published in Political Quarterly 1st May 2018)
On the 4th July, the National Health Service will celebrate its 70th birthday and there will be much fanfare and celebration. The NHS has been described as one of the greatest social achievements of the 20th century with its promise to care for the British people from cradle to grave. But all is not well.
Intense financial pressure
The NHS was established as a publicly funded, publicly provided and publicly accountable service but the systems and mechanisms which ensure health care for all are now being progressively dismantled and NHS funding is being reduced and diverted to private operators and their shareholders.
Despite a rising tax base – the population has increased by 2.5 million and is predicted to grow by 440,000 a year over the next ten years health care needs are not being met. This is because the government has taken a political decision to reduce NHS services so that those who can pay will pay and go privately.
The visible signs of reductions in funding and diversion of funds to private operators are the closures of hospitals, GP surgeries and community services and sales of NHS estate. NHS England has cancelled tens of thousands of hospital operations, much needed operations which in turn are creating the biggest backlog in the health service’s history. A&E services are in a near permanent state of crisis on a daily basis and on many days some hospitals report having no hospital beds available with bed occupancy levels over 100 per cent.
All the key indicators within the NHS worsened over the last few years, with waiting lists reaching 10-year highs. A shortage of doctors, nurses, beds and care packages for elderly patients means that black alerts, trolleys in corridors and dangerous safety levels for patients are at a peak. What was once confined to winter is now an all-year-round occurrence.
As financial and operational performances deteriorate any additional resources allocated to the NHS by the government are being used to bail out hospitals with large deficits and enormous annual PFI charges. Precious NHS resources are being squandered on management consultants, lawyers, accountancy firms, PFI contracts and commercial contracting. Commercial contracting creates waste and fragmentation of care and risks are passed from commissioner to provider to patient like a sinister game of pass the parcel.
Faced with large financial deficits NHS managers holed up in their offices and board rooms look at how they can use their new powers to generate private income – now that NHS foundation trust hospitals can generate up to half their income from private patients and other sources. At the same time Foundation Trusts are undertaking more privatisation and entering into joint ventures and creating companies to transfer staff.
Dismantling the NHS
The fear of the financial costs of ill health is rapidly returning. The principle of a universal healthcare system free at the point of use is broken. This government has ushered in a creeping reduction of universality, with the withdrawal of entitlements and demonisation of ill people, old people, immigrants, asylum seekers, refugees alongside the incremental rationing of care, for example Windrush migrants and introduction of health care migrant charges. For 70 years people were treated on the basis of need not screened for their eligibility.
The government’s new plans for health care, which are being rapidly introduced and without proper public debate or parliamentary scrutiny, turn on new models of care are drawn from the US – the most expensive and unfair system in the world.
These new models labelled and relabelled ACOs, STPs, ICS, ICPs, MCPs PACs have one endpoint – the Accountable Care Organisation. The government plans to drum up billions of pounds and award giant contracts for at least ten years to private for profit providers.
The government calls this integration. The reality is that commercial contracting will involve transferring statutory decision making for planning and resource allocation to non statutory bodies. In this way risks and costs of care are shifted to patients are shifted to patients.
The NHS is being fragmented, undermined and decimated. There are no countries that provide universal healthcare on this basis. The legal basis for shifting commissioning functions to non-statutory bodies is currently being challenged in the court and the hearing of the judicial review will be heard on 23rd and 24th May, funded by the public.
The Health and Social Care Act 2012 removed the duty on the Secretary of State to provide universal health care throughout England and ushered in market competition. It dismantles the NHS. Only parliament can restore what parliament has taken away and this needs legislation.
Reinstating the NHS in England
The intergenerational unfairness which has made individuals responsible for long-term care must be remedied and means testing and privatization of care ended. Mechanisms for public accountability must be renewed.
We should restore the founding principles of the NHS through national terms and conditions of service for doctors and all NHS staff. Above all, we must allow professional standards to thrive since these are the basis of public and patient trust.
In its 70th anniversary year, what the NHS requires is not reform but revolution – a quiet, collective revolution that brought the NHS into being in the first place.
Kailash Chand is honorary vice president of the British Medical Association (BMA) and has worked as a GP since 1983.
Judicial Review on ACOs:
The Bevan model is no longer fit for purpose.
A centralised undemocratic service with little accountability is an obsolete public service.
There should be democratically elected health commissioners. Independent contractor status for GP.s should end and the CCG GP dominated commissioning process ended.
Foundation Trusts with their tiny democratic franchising system should be far more integrated into local government structures
It goes further than this, because what is currently called representative democracy is often ineffective and unconvincing to the public, notably the EU version. We shall either have to deepen democracy or lose it. To give one example, service on a trial jury is mandatory and to some extent compensated. Why should service on a Citizens’ Jury (sortition) not be similarly mandatory and compensated? And no doubt there will be other organs of democracy developed. My experience of my local Health and Wellbeing Board is rather mixed. I wouldn’t want to see them simply put in charge.
Interesting, but is it realistic to expect sufficient people to show an interest and vote for a health Commissioner? I understand it was tried in Scotland and abandoned through lack of interest.