United Nations House Scotland, Roundtable on the Human Right to Healthcare
27 April 2023
Talk given on behalf of KONP by co-chair John Puntis
Many thanks on behalf of Keep Our NHS Public (KONP) for the invitation to speak. KONP was set up in 2005 to oppose privatisation and to campaign for a publicly funded, accountable, and delivered health service based on the NHS founding principles.
I’m speaking from the perspective of England’s health care system. I am not knowledgeable about the systems in devolved nations. Scotland did take an important stand against the marketisation of health care by abolishing the purchaser-provider split, but even though health care is a devolved matter, funding through the Barnett formula means that, when public services are starved of cash in England, Scotland is also directly affected.
The founding principles of the NHS
The founding principles of the NHS were that it should be universal, equitable, comprehensive, high quality, free at the point of delivery, and centrally funded from taxation. Note that at a time when the economy had been wrecked by six years of war, this demonstrated huge ambition and remarkable political leadership. The philosophy was that in order to have a strong economy, you needed to have a strong health service. This is the opposite of the current mantra of those in power – that you can’t spend money to improve public services until you have a strong economy.
The founding principles are reiterated in the NHS Constitution for England which, while recognising that funding is finite, asserts that public funds for healthcare should be devoted solely to the benefit of the people that the NHS serves.
The World Health Organization’s (WHO) aims accord with those founding principles, and are aligned with the Sustainable Development Goals, focusing on achieving universal health coverage, including financial risk protection, access to quality essential healthcare services and access to safe, effective, quality and affordable essential medicines and vaccines for all. I am going to explore how universal health care in England has been undermined
The NHS is now in crisis, but this is a recent phenomenon
The US Commonwealth Fund periodically examines healthcare systems in the world’s richest countries and looks at what lessons might be learned for the US system – the most expensive, yet the one with the worst outcomes (proving of course that it is not just how much money you spend on health care but also how you spend it that is important). The NHS ranked first in these assessments from 2007 to 2017, but fell to fourth in 2021. The reasons for this decline relate in large part to delays in being able to access care and treatment, and lack of investment.
The Government in England thinks the NHS is going through an “extraordinarily difficult patch”, blaming variously the covid pandemic, strep A infection, flu, staff sickness, and delayed discharges. Most who work in the service believe it is experiencing the worst crisis in its history due largely to lack of workforce planning and chronic underfunding. This was also the assessment of the Commons Select Committee on Health and Social Care, and indeed an independent review from the King’s Fund commissioned by the Department of Health and Social Care!
There are around 150,000 staff vacancies out of a total workforce of 1.3 million (1 in 9). 150,000 beds have been lost over the last 30 years, including 20,000 in the past decade, and 5,000 because of covid infection control requirements. Waiting lists have risen to an astonishing record of 7.2 million. The number of working age people claiming disability support has doubled post-pandemic. Record numbers of people are taking early retirement, most commonly because of ill health. Nine million people are now ‘economically inactive’, with 27% giving long term sickness as the reason. All of this shows that the UK simply cannot afford for the NHS to fail.
There are some stark figures on how patients are being affected. For example, according to peer reviewed research, delays within emergency care are leading to 500 deaths/week. The Chief Ambulance Officers report estimated 160,000 incidents of patient harm from ambulance delays in one year, and there were 500 deaths last year from late ambulance responses. For non-urgent care, since 2019, over 500 people have lost sight because of not being able to access treatment in a timely fashion.
Commenting on all this, the president of the Royal College of Emergency Medicine observed that pressure on the NHS is now so severe that it is breaking its ‘basic agreement’ with the public to treat the sickest in a timely way, identifying the true barrier to tackling this crisis as political unwillingness.
Underfunding is a real issue
Despite the government insistence that the NHS has never had so much money, a convincing case can be made that it remains underfunded. Annual budget rises up to the banking crisis were always around 4%, but fell to 1% as part of the Conservative government’s austerity programme. Incidentally, it is estimated there were 335,000 excess deaths related to austerity from 2012-2019. The NHS may have had more money overall, but it has not been allowed to grow as the population has increased in number and age, and new treatments come along. The British Medical Association estimates that if funding had continued on the same trajectory as during 2001-2010, the NHS would now be getting £60bn more each year. Bear in mind that the UK has the sixth largest economy in the world; some comparable EU countries are spending around 25% more per capita on health care, going a long way to explain their better outcomes; the Health Foundation estimated that we spent £40bn less each year for ten years up to the covid pandemic.
The NHS is not profligate with its funding, although administration costs increased from 5% of budget to 14% with introduction of the market reforms, and is probably now even higher. This could be a key focus for reducing costs. Far from being inefficient, the NHS increased productivity from 2004-2016 by 16.5% compared with only 6.7% in the economy as a whole. Neither is it overmanaged with only about 3% of its workforce being managers, compared with the industry average of around 12%.
I would agree with the very incisive comment made recently by Anita Charlesworth of the Health Foundation when discussing the crisis in emergency care: there is no route to a better NHS that is not an adequately funded NHS.
Government response to managing the NHS
The government approach to the problems of the NHS has been structural reorganisation (usually termed ‘reform’) rather than investment in staff and infrastructure, for example the 2012 Health and Care Act which put competition at the centre of its strategy. We now don’t have enough capacity particularly to deal with the backlog of care from covid, for example there are 2.2 beds/1000 population in the UK versus 8/1000 in Germany and an average of 5/1000 in the members of the Organisation for Economic Cooperation and Development; only Sweden has a lower number of beds, a country where there has been significant investment in community services.
There is still much NHS estate that is old and no longer fit for purpose, yet capital funding is not forthcoming and lags £33bn behind other European countries. There is an estimated maintenance backlog of £10 billion. None of the promised 48 new hospitals have been built or even approved and funded for that matter, and there are 34 hospital buildings in imminent danger of collapse, including King’s Lynn Queen Elizabeth Hospital being held up by thousands of building props.
The example of dentistry is a warning of what may happen to the rest of the NHS
Dentistry is a good example of what may happen to the NHS as a whole. Top up charges for most adult patients were introduced in 1951 and increased every year; it is clear that these charges have become a barrier to care for many. Driven by changes to the dental contract under the last Labour government, preventive dental care was given little priority and dentists could only perform an amount of work agreed in advance even if demand increased. Smaller practices are being priced out and taken over by private companies, so that most dentistry is now performed in the private sector. There are 8 million people in England who are not registered with a dentist, and only 1 in 10 practices are accepting NHS patients. There is clear evidence that oral health is deteriorating, particularly in children. The impacts of poor oral health disproportionally affect the most vulnerable and socially disadvantaged individuals and groups in society.
The end of universal access
Universal access to health care effectively ended with the introduction of the euphemistically named overseas charging legislation, part of the hostile environment. The Immigration Act of 2014 meant the definition of ‘ordinarily resident’ (a qualification for NHS treatment) was modified to mean you had to have indefinite leave to stay. This meant that undocumented people (thought to number between 800,000 to 1.2 million) were liable to pay for many NHS services. The charging system contradicts a global commitment to Universal Healthcare Coverage defined by the WHO as ensuring access to needed health services while also ensuring that the use of these services does not expose the user to financial hardship. This is included in Sustainable Development Goal 370. The UK is also a signatory to the International Convention on Economic, Social and Cultural Rights in which Article 12 explicitly lays out a human right to the highest attainable standard of physical and mental health. This right is not dependent on migration status, but rather applies equally to all people.
A number of treatments have been withdrawn from the NHS on the basis of lack of evidence for effectiveness and some medications such as simple pain killers are no longer available on prescription and neither are gluten free foods for patients with coeliac disease; often these treatments are still available in NHS hospitals to self funding patients, and through private clinics. One example is removal of benign skin lesions such as moles on the face or cysts on the scalp, which can be very distressing to patients. NHS England’s rationale was partly to prevent unnecessary harm. Ironically, reports followed of increasing numbers of people being burnt and scarred after taking themselves for treatment to high street beauticians who were not qualified to provide this service and were also oblivious to potential signs of skin cancer. The huge waiting lists are also a very obvious form of rationing. The new Integrated Care Systems in England are currently being asked to find savings of £12bn and also threatened with strict financial controls, expected to result in denial of care and cuts to services.
How much the NHS has been privatised is contested. The WHO defines privatisation as “a process in which non-governmental actors become increasingly involved in the financing and/or provision of healthcare services”. If we take this broad definition, the government’s attempt to deny privatisation of the NHS by claiming that services remain publicly funded and free at the point of delivery does not escape the WHO definition, even when services are delivered by non-governmental actors, such as third sector voluntary and community organisations.
David Rowland of The Centre for Health and the Public Interest (CHPI) found that about 18% of the NHS budget made its way to private companies. CHPI estimated that there were around 53,000 individual contracts which underpin flow of money between the NHS and the independent sector, worth £29 billion each year. Over 50% of hip and knee operations are now done for the NHS in the private sector, and nearly 50% of cataract surgery. Increasing numbers of people are opting to pay for private care mainly because of long delays in the NHS. Private companies are profit maximisers and not cost minimisers; private contracts take money away from the NHS. Outsourcing is associated with poorer quality of care, worse patient outcomes and worse terms and conditions for the workforce.
Are we moving towards a two-tier system?
Since 2014, the private sector has invested £2bn in newly opened acute health care facilities; the NHS has spent only £761 million on large hospital developments. Over the past two decades government has actively grown the private health care sector in the UK through a series of policy initiatives. Recent history shows that when the government invests substantially in the NHS, private healthcare spending drops and public satisfaction increases. A two-tier healthcare system in the UK is not an inevitability. Its likelihood depends on political decisions about funding for the NHS, investment in new healthcare facilities and an expansion of the healthcare workforce. According to Rowland, if a two-tier system does emerge over the next decade, it will be to the detriment of the health of the population and is likely to exacerbate the high levels of health inequalities in the UK. He argues that re-affirming the founding principles of an NHS which provides care based on need rather than ability to pay is critical to maintaining and improving population health.
What does the public think about the NHS?
The recent British Social Attitudes survey on health and social care findings makes grim reading. Overall satisfaction with health has fallen to its lowest point in 40 years, to 29% down from 36% the previous year. 40% are ‘very’ or ‘quite’ dissatisfied with emergency departments, but there were drops in satisfaction across all areas of care. Staff surveys also show increasing levels of stress and dissatisfaction, and a 70% rise since 2017 in number of staff days lost through mental health issues. However, like in Health Foundation and Ipsos Mori surveys, public support for NHS founding principles was found to remain high across the political spectrum. The Ipsos poll found that only 8% of people in England think the government has the right policies for the NHS, while 90% wanted care free at the time of delivery, 80% comprehensive services, 84% funding to be through taxation, and 82% more funding (63% Con voters, 94% Lab).
So what should be future look like?
In the 2018 Astana Declaration on primary healthcare, the WHO envisioned governments and societies that prioritise, promote and protect people’s health and well-being, at both population and individual levels, through strong health systems; primary health care and health services that are high quality, safe, comprehensive, integrated, accessible, available and affordable for everyone and everywhere, provided with compassion, respect and dignity by health professionals who are well-trained, skilled, motivated and committed. In the UK as a whole we should not be complacent about where we are now, and current policies from the major political parties give little cause for optimism.
Working with the Independent Scientific Advisory Group for Emergencies, KONP developed an outline of what lessons might be learned from the covid pandemic. In a nutshell, we need effective, equitable and resilient health and care services. This is not unaffordable, and it must be regarded positively as an asset, and not negatively as a cost. Privatisation does not bring efficiency, and public health cannot simply be about personal choice.
Politicians are clearly out of step with what the public want for the NHS. KONP is working to build a broad-based campaign that will harness public outrage and build effective political pressure that will result in a health care system once again based on the founding principles of 1948.
Dr John Puntis
Co-chair Keep Our NHS Public