John Puntis, Co Chair of Keep Our NHS Public analyses Keir Starmer’s plan for the NHS announced on 6 January 2025
▪︎Crisis in acute care ignored
▪︎Elective Care – embracing privatisation
▪︎Plan disatrously enhances and entrenches role of private sector
▪︎Critical responses to plan
▪︎Lack of protections against private sector seriously lacking
▪︎Major omissions from plans
Introduction
The current crisis in the NHS is all too evident, with 6.4 million people waiting for 7.5 million procedures and around 1 in 8 beds taken up by those fit enough to go home if only community services and social care were available. The government has pledged to bring waiting times down for non-urgent treatment to 18 weeks for 92% of patients by March 2029 (65% by March 2026). This is an ambitious target and entails getting three million people off the waiting list. It would be an improvement in NHS performance comparable to that achieved by New Labour in the 2000s, but then investment in the NHS was the single biggest factor in the improvements. The context now is a very different being one of a service in a far more parlous state – understaffed, starved of capital funds, and with no promise of new money.
What about the crisis in acute care?
The crisis in acute care has been brought home by the predictable rise in winter viruses, including influenza, norovirus, covid and respiratory syncytial virus. Inability to discharge patients and free up beds means that around 14,000 people are dying each year because they cannot be moved quickly from A&E to appropriate wards for treatment. Overfull emergency departments cannot accommodate patients arriving by ambulance and they wait outside, cared for by ambulance crews. Paramedics stuck outside hospitals are failing to answer 100,000 999 calls each month. Only 1 in 6 Emergency Departments consider they could cope with a major incident.
Figures recently released by NHS England showed that 2024 was the busiest year on record for A&E and ambulance services. Shocking stories have arisen of patients waiting 91 hours to be seem, and a pensioner being told by desperate staff that if they did not agree to give up their bed for another patient, a charge of £582 would be levied for each night. Care in corridors and car parks (‘temporary escalation spaces’ in official jargon) has become normal in many hospitals. This is terrible for patients but also putting huge strain on staff.
Starmer’s speech
On the 6th January 2025, Prime Minister Keir Starmer launched the Elective Care Recovery Plan in a speech at the South West London Elective Orthopaedic Centre in Epsom. This plan is framed as a partnership with the Independent Sector (aka ‘NHS dependent private sector’). He stated that rebuilding the NHS was the cornerstone of a plan to rebuild Britain, mentioning ‘free at the point of use’ as a key principle but as usual omitting ‘publicly provided’. Warning that the NHS could not go on to become ‘the national money pit’, he then disingenuously misrepresented NHS productivity as 11% lower than pre-pandemic. In fact, before the pandemic, NHS productivity growth was faster in the NHS than both the rest of the public sector and the economy as a whole. Now, after a post-pandemic fall-off, NHS hospital productivity has increased over the last year, with hospital activity growing faster than staffing.
Starmer went on to explain that ‘this is the year we roll up our sleeves and reform the NHS.
A new era of convenience in care. Faster treatment – at your fingertips. Patients in control. An NHS fit for the future’. Pausing to give a plug for an AI enhanced stethoscope, he enthusiastically if incorrectly suggested such a device could ‘save a patient in an instant’. Labour of course has high hopes of AI and intends to ‘unleash’ it on the nation. This includes unlocking public data to help fuel the growth of AI businesses, with emphasis on potential benefits but little focus on the many inherent risks.
In a plan that we were assured is totally ‘unburdened by dogma’, key elements were set out for a new agreement between the NHS and the private healthcare sector which will allegedly make the spaces, facilities and resources of private hospitals more readily available to the NHS. The problem here of course is that the small private sector (around 9,000 beds versus 140,000 in the NHS) does not have spare capacity and can only develop this at the expense of the NHS, including taking staff away from NHS work. One example of the negative consequences of using the private sector to bring down waiting lists can be seen in ophthalmology and cataract surgery. NHS departments have been deprived of staff and funding but left with the care of complex conditions where delays in treatment may mean that patients lose their sight. This is prioritising the short-term goal of reducing waiting numbers without due regard to ramifications and unwanted negative consequences.
Elective Care Recovery Plan – embracing privatisation
It is claimed that this plan will deliver the waiting list targets through two million extra appointments a year; 440,000 appointments in community diagnostic hubs working longer hours (12hr/day, 7 days a week) with same day tests and consultations; 14 new surgical hubs in hospitals, and three expanded hubs. It is hoped that by enhancing the NHS App one million appointments might be obviated, with the onus on patients to request follow-up. There will be the reintroduction of financial incentives to providers, with GPs expected to reduce referrals and hospitals to cut waiting times. The private sector estimates it can provide 1 million more appointments annually, for which it will be paid £2.5bn (£2,500 each!) with a focus on reducing waits in gynaecology and orthopaedics. This amounts to an overall 20% increase in private sector activity.
Entrenching and boosting role of private sector
The plan incorporates three strategies for further boosting the role of the private sector.
1. Firstly, for digital integration, with NHS and private sector digital systems being aligned around national standards, allowing patients access to appointments and results via the NHS App.
Note that the private sector is far from transparent in terms of activity, capacity, staffing and costs – in fact it is currently a black hole when it comes to data.
2. Long-term contracts will be encouraged in order to attract private sector investment in NHS capacity (demolishing any argument that private sector ‘help’ is only short term until list sizes come down).
3. It is proposed that both sectors will collaborate to grow and develop the elective workforce, ensuring consistent training in the independent sector. This makes the huge assumption that relevant quality training is even possible in small (average 50 bed) private hospitals dealing with a limited range of non-acute work, and that the sector has suddenly become willing to invest in training. It is most likely included to forestall the valid criticism repeatedly levelled that the private sector does not train staff but takes them from the NHS pool; this is not likely to change.
So much is the private sector to be embraced that it is now the government’s wish for it to be planning services together with Integrated Care Board’s. This goes even further than the Conservatives dared to suggest. Once again ‘patient choice’ is being used as a driver towards the private sector, with the risible suggestion that the latter will commit ‘to reviewing their clinical exclusion criteria to ensure these allow choice of an independent provider for as broad a cohort of patients as possible, subject to the ongoing provision of safe services’. We know that not only are private services located in the most affluent areas (their use by the NHS being likely therefore to exacerbate health inequalities), but that they have to cherry pick simple cases yet still have significant safety issues with 6,600 patients a year being transferred into NHS hospitals.
Critical responses to the plan
Many are sceptical that the waiting list targets can be achieved without investment in supporting and growing the NHS workforce (there are now 108,000 vacancies in secondary care). Community diagnostic hubs take staff from hospitals where the majority of work is done, thereby fragmenting services and undermining multi-disciplinary teams while increasing costs. NHS Surgical hubs may have a role but are concerned with high volume low complexity operations to the possible detriment of patients with severe problems. The recovery plan’s sole emphasis on elective care misses out major pressing concerns over waits for GP appointments, ambulances, mental healthcare, and other services. The overall state of the service cannot simply be assessed on the basis of waiting lists.
Upgrades to the NHS App disregard large numbers of people who for various reasons are digitally excluded and misses the point that priority for treatment must be given to those most in need. Emphasis on digital is very likely to prove the accuracy of the ‘Inverse Care Law’ (i.e. those most in need are most likely to lose out, and even more so when care is subjected to market forces). Financial rewards for better performing hospitals introduce perverse incentives with potential negative impact on quality, as well as being detrimental to those hospitals often struggling through no fault of their own. Existing financial pressures are being ignored, with ICBs having to find an implausible £8bn in ‘efficiency savings’ and 39/42 ICS failing behind in their financial plans.
Plans to monitor private sector like ‘chocolate fireguards’
Those involved in management and governance of the NHS would do well to understand that the private sector is a competitor and not a helper and that the world of business is ruthless. It has been pointed out that reliance on the private sector to deliver core NHS services is ‘incompatible with the sustainable delivery of first-class healthcare, across the entire population, at reasonable cost to the public purse’. Sensitivity to criticism that the private sector is more of a parasite than a helper has led to various statements suggesting that contracts wont be allowed to negatively impact the NHS. This has of course already happened in ophthalmology without any due notice or concern from the Department of Health.
The following might therefore be rightly regarded as being in the realm of ‘chocolate fireguards’:
‘Independent providers should ensure that capacity offered to the NHS provides additionality to system capacity and is capable of being staffed without having a material impact on the existing local NHS workforce.’
‘Independent providers commit to providing support in the most challenged specialties when enabled to do so’.
‘One of the barriers to effective patient choice is the conflict of interest that arises when referrers deliver part of the patient pathway (including follow up care) – think high street opticians incentivised to refer patients with cataracts.
‘All providers commit to ensure that they do not provide incentives that distort patient choice’.
‘NHS and independent healthcare employers should work together to identify existing and future local staffing requirements to support workforce planning and professional training.’
If these were to be rigorously applied, it is difficult to see that there would be any private contracts.
Evidence shows that when the NHS was funded to succeed it offered the best health care.
New Labour’s investment in NHS staff and facilities was the key to bringing down waiting lists in the 2000s and increasing public satisfaction, and not deals with private sector. Diverting public funding to the private sector (so that it can create ‘spare capacity’) undermines the funding and staff available to the NHS and provides a worse service. Public money will be used to expand private capacity, guaranteeing private profits and minimising risk. This approach is consistent with reported discussions around a giant Private Finance Initiative arrangement with asset management companies and will prove more expensive than the Government directly investing in the NHS. Long-term contracts and guaranteed profits from the public purse may even mean that extra capacity is never even owned by the NHS.
Aligning the private sector with digital integration, workforce development and training, joint planning of services and long-term contracts gives it a more powerful foothold in the NHS for no evidence-based reason. Low paid workers’ terms and conditions are worse in the private sector and contribute to worse care for patients. NHS team working is undermined and corners cut. So, far from those who oppose private contracts in the NHS being ideological, it is a misguided and ideological choice of Government to invest in the private sector at the expense of rebuilding the NHS.
Major omissions from the plan
Labour’s recent announcements show that there is really no coherent plan for the NHS. The Government is wrongly prioritising expansion of the private sector and failing to address the national emergency in acute care. The most glaring omission is surely social care given the enormous strain this is putting on the NHS. Lack of access to dental services is causing misery for millions, yet there is no progress with a much needed new dental contract and a promised increase in dental appointments does not seem to have materialised.
General Practitioners remain in dispute over funding of their new contract. They are doubtless bemused at the shift from being ‘the front door to the health service… the key to earlier diagnosis…. We will bring back the family doctor… so ongoing or complex conditions are dealt with effectively’ in the Labour manifesto, to ‘not formally part of the NHS’. This last comment from Wes Streeting related to alarm calls from GPs that employer National Insurance increases would lead to the closure of some practices.
Many GPs are understandably wary about their assigned role in the plan, including a measly £20 for each patient they discuss with, rather than refer to, a specialist. This, plus expecting them to access more tests for diagnosis, is a further way of transferring hospital work to a group already beset by overwork and financial uncertainty.
Finally, we should note that delay seems to be the name of the game, with the Ten Year Plan for the NHS put back to the summer, the social care commission taking three years, important pay talks with unions delayed, and decisions about the future of Physician and Anaesthetic Associates postponed subject to a review.
KONP’s Vision for a People’s NHS
KONP’s ‘Vision for a People’s NHS’ sets out what needs to be done to restore the NHS; it calls on politicians for a commitment to public provision and ending outsourcing. The founding model of the NHS is the best basis for providing comprehensive and universal care while also being essential to the economy: this is convincingly set out in ‘The Rational Policy Maker’s Guide to the NHS’. Emergency funding is needed now to strengthen community teams, provide more beds to reduce pressure on emergency departments, and address the huge and growing maintenance backlog.
KONP agrees with Lord Darzi that we cannot afford not to invest in the NHS. There is an urgent need to address staff retention as well as recruitment, based on a new workforce plan that realistically assesses current and future workload. No new PFI deals of any kind should be contemplated and existing ones that are draining NHS resources could be nationalised or renegotiated in the public interest. Where private sector facilities exist and are not being used, these could be acquired for the NHS. Reform of social care can no longer be delayed and should be focused on building a National Care, Support and Independent Living Service, ending the misery of many needing care and support, together with that experienced by their families and carers.
The Elective Care Recovery Plan takes us to a pie in the sky world where fierce private sector competitors (who would never dream of divulging their own business plans and long term profit-driven aspirations) will ‘affirm their commitment to working as part of the tax-funded free at the point of use NHS in support of that goal and to work with the NHS to strengthen the overall healthcare system in England’.
The plan is focused on the controversial, costly and counterproductive increase in the use of the private sector rather than investing in expanding NHS capacity. The acute care crisis is ignored (so much for the promise of ensuring that ‘staff are able to give the standard of care they desperately want to’). This is a continuation of successive government policy that has actively grown the private sector over the last two decades. Many expected better of Labour, voted in on the promise of change and gaining a massive parliamentary majority. Bevan must be spinning in his grave.
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