KONP discussion paper
We are preparing this document at a time of great uncertainty. The current government has a majority which ought to mean that there are two more years before a general election but things could change more quickly than that. We wish to engage with all opposition parties, putting forward our expectations of effective opposition action, our fundamental aims and goals, together with the top priorities for urgent action which will be needed to put the principles into practice.
Building the narrative in opposition
Government policies in recent years have resulted in: the shrinkage of the NHS relative to the need for health care, primarily through
(a) a funding policy where annual funding increases (of 1-2%) fell well below the historic average up to 2010 (4%),
(b) a disregard for the impact of policies on NHS staff giving rise to the worst staffing crisis the NHS has ever experienced,
(c) the reduction in hospital capacity without the corresponding adequate expansion of community services and
(d) an excessive pre-occupation with structural reorganisation, most recently through the new, hugely problematic Health and Care Act.
A consequent rise in waiting times had increased markedly prior to the pandemic, with a near doubling of the waiting list, and has now been exacerbated by it. This itself has resulted in a loss of confidence by the public that the NHS is able to meet their need for health care when it is required and prevent patients from resorting to the purchase of private health care to avoid extended waiting lists.
Vigorous opposition on health policy will:
- Enable the public to see more clearly the policy direction of the Conservative government and its impact on fundamental principles of the NHS.
- Restore hope and inspire members of the public who are demoralised by years of austerity, impoverishment, the deterioration of public spaces and decline in the quality of public services
- Check the fear there is no alternative to current government policies
- Raise the bar and increase the standards of accountability to which government is held
- Sustain democratic processes by maintaining a values-based discourse, scrutinising government policies, articulating alternatives, and broadening the range of policy ideas
- Create a sense that the opposition merits election to government on the grounds of vision, values, trustworthiness and ability to implement sound policy
Essential to effective opposition are the following:
Opposition parties should not remain silent in the face of unacceptable policies but speak up and denounce government policies which move the health service in the wrong direction.
The health teams of opposition parties should develop a strategy of opposition with clear goals and a clear division of labour among members of the shadow team in order to maximise impact. This needs to ramp up from the present so that it reaches a point by the next election where the electorate are crystal clear that the NHS can be saved with a change in government.
The leadership of opposition parties should follow democratic processes in arriving at policies and get feedback from their membership and relevant bodies such as ourselves, the country’s biggest health campaigning organisation. As part of this process Keep Our NHS Public will include demands to renationalise the NHS as a universal, comprehensive health service, publicly provided, publicly accountable, publicly funded, free at the point of use with treatment decisions on clinical grounds, not ability to pay. Opposition parties could be united on ending privatisation and on funding the NHS properly to meet need.
Local councillors play an important role in implementing current government policies for health and social care. The leaders of opposition health teams should give their councillors clear guidance on how to handle these issues, so that we can be as well prepared as possible for a change of government at the national level.
Opposition parties should engage the public in their strategy of opposition. Unless the government’s majority is wafer thin, opposition parties facing a majority government by definition do not have enough votes to win their case in the House of Commons. This means that effective opposition on major pieces of legislation is unlikely to succeed solely through a parliamentary strategy. Effective opposition will require taking the issue to the public and building up public opposition to the legislation so that popular rather than merely parliamentary opposition can be brought to bear.
Opposition parties should declare their own policies. Policies designed to fulfil stated visions for health and social care should be communicated to the public sooner rather than later in the parliamentary cycle and actively advocated. The absence of policies deprives the public of any sense of what a party stands for; it breeds distrust as there is nothing ‘solid’ and enduring about the party and creates the impression a party lacks fundamental values and produces policies only for the purposes of expediency.
Opposition parties should actively advocate for their vision and for the policies through which they aim to fulfil their vision. This helps shape the agenda for debate and checks the ability of the government to define the political agenda and the scope of feasible policy options.
Opposition parties should build a case for their policies over time and embrace the need to raise the level of debate and public awareness. This would include building a case: for redistribution and other policies which address inequalities in health and wellbeing; for expanding health and social care provision; for pay increases for social care and health workers; and advocacy of other policies as set out below. Focusing solely on government incompetence and sleaze gives the impression an opposition party has no policies of substance to promote and lacks confidence in its ability to persuade the public to support policies which are different from government policies.
Specifically, urgent opposition action is required on:
- The difficulties experienced by the NHS in driving down the waiting list
The failure to fund the NHS adequately over the period of a decade has created a situation in which it is now difficult for the NHS to recover performance and this is exacerbated by significant levels of ongoing Covid-19 admissions. The public needs to understand why, in the face of what appears to be significant additional funding, waiting times remain poor and waiting lists continue to grow.
- The increasing use of public money to contract from the private sector instead of expanding the capacity of the NHS
This results in drawing staff and funding away from the NHS, progressively weakening it, cherry picking patients by the private sector leading to greater inequalities, and increasing 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.
- Government pursuit of policies without regard to their impact on staff and the failure to care for and value NHS staff and social care workers.
A commitment to improve pay and working conditions and to safeguard professional status is essential for staff morale, for safety and efficiency.
- Failure to reduce adequately economic inequalities through taxation, social security and welfare state services.
- Failure to tackle the wider determinants of health, for example through redistribution and the reduction of economic inequalities.
- Failure to fund social care services adequately and develop a national social care, support and independent living service which is publicly funded, not for profit and free at the point of use like the NHS.
Such a service needs to be developed in partnership with service users, sector workers, families and local communities to provide the personalised, community-based services people want and need. It also needs to ensure good working conditions and pay for care and support workers. A commitment to a radical transformation of Social Care is essential.
- The abandonment of the requirement to self-isolate for those testing positive for Covid-19 and of financial support for those who do.
A commitment to restoring WHO-backed public health pandemic policy and protective measures including ventilation and air quality, appropriate mask-wearing and availability of PPE for relevant frontline staff, and financial support for those who need to self-isolate is essential.
- The shrinkage of the NHS relative to need and unrealistic targets for “efficiencies” among NHS providers.
A clear commitment to adequate funding, the retention of taxation-based funding and expansion of NHS capacity to reduce waiting times is essential.
- Numerous aspects of the 2022 Health and Care Act and associated Guidance.
- Fragmentation of a national health service into 42 autonomous health services, each with a strictly capped budget and “core responsibility” for a local population with clarity as to what “core responsibility” excludes
- Potential membership of the independent sector on ICB committees and sub-committees (and other ICS bodies) and increased opportunities for private companies to drive NHS policy and management at local and national level, stripping the NHS of in-house capacity and creating further opportunities for the profit-driven private sector
- The failure to guarantee comprehensive and universal care for people present in the geographical patch of an ICB, including people who are visiting from other parts of England and the UK and people who are undocumented
- Unequal access and postcode lottery at ICS level
- Reduced accountability to local people
- Private companies given access to confidential patient information with no clear protection for patients, and potential for private profit from patient data
- Increased reliance on protocol driven services, replacing patient-centred treatment based on professional expertise
- Growing expectation that patients will ‘self-care’ using phone apps or websites for advice and information, and increased digital services, creating a two-tier health service and reduced care for most vulnerable people and those for whom digital access is inappropriate, including those without access to the requisite IT
- Fewer face-to-face appointments with GPs; increased use of staff with limited training and skills, working to set protocols, and who are likely to miss important diagnostic features
- The move towards a more restricted range of NHS services available to all, including many ‘low level’ services such as ear wax removal or chiropody which are nevertheless vital for healthy living, especially for older and/or disabled citizens
- The discharging of often vulnerable patients from hospitals without ensuring that any required follow-up care is in place
- Replacement of local general hospitals and Accident and Emergency Departments with centralised hospitals, resulting in greatly increased travel times and inconvenience or hardship for patients and visitors
- Power of Secretary of State to remove professions from regulation, and to merge or abolish regulators.
A commitment to addressing these dangerous flaws is essential.
Fundamental aims and goals to be pursued
1 Collective funding from progressive taxation. Pooling of risk, with comprehensive health care for all, with health care resources allocated according to need. No shift towards greater funding through NI which privileges those living from unearned income and differentially penalises lower-paid workers. The impact on economic growth of additional spending on health care through the fiscal multiplier should be recognised.
2 Public provision of services which are free at the point of use. Health is not like retail where the customer is king, but is characterised by information asymmetry, where the provider is likely to know more about what is needed than the user. Profit-driven distortions – where there is competition resulting in undercutting through reducing costs and the skills profile of the workforce – should be eliminated so people can know that the staff who treat them are working in their interest. Public provision is most cost-effective when funded properly, as international comparisons show.
3 Organising for health equality improvement. Recognise the primary role of the public health function and collective measures implemented in numerous domains, mostly outside health care, to maintain wellbeing and sustain health, reducing the prevalence of disease. Deep health inequalities in the UK require that the whole health and care system should be driven in part by the objective of reducing it. The full range of central government departments, not just the Department of Health but especially including the Treasury, need to be united in a strategy for reducing health inequality. This will require some devolution of powers to act to the level of place. There is no simple structure which will both recognise the need for universal service to individuals and deal with the wider determinants of health inequalities. Devolving key planning and decision-making to place-based partnerships is a positive route to addressing this.
4 Resilience in the face of the threat of global pandemics. Strengthen the hand of public health function in preparedness and management of infectious disease. Ensure that all services such as the provision of PPE and the test and trace system are publicly delivered, retaining a surge capacity for when emergencies arise. Full transparency about this function should be embedded in a role for parliament and not only be held in the executive.
5 Expand capacity of public NHS provision in acute hospital, primary, mental health and community care so that waiting times are driven down by greater NHS capacity. Purchasing capacity from the independent sector does not solve the problem as it recruits NHS-trained staff and piggybacks on public resources as well as increasing inequalities and reducing accountability. It diverts resources away from NHS provision and, in the process, channels part of the NHS budget into profit or other forms of surplus, both of which parasitic costs are avoided when services are publicly provided. As a result, any gains envisaged from private sector provision are illusory.
6 Primary care. There is a need to re-emphasise the importance of primary care as the cornerstone of the NHS, guaranteeing universal access to a GP and the primary care team services.
6 Adequate levels of funding are essential if high quality and timely health care is to be provided. On principle, a well-funded service with capacity to meet the needs of the population – including with resilience to cope with emergencies, pandemics and surges in need – is safer for patients and for staff, more efficient and cost-effective and ensures continuity of service. Make commitment to achieving a level of spending on healthcare similar to that of comparable countries by the end of the parliament.
7 Public accountability. In a service which matters so much to the public and where there has been so much justified mistrust in recent years, it is a high priority to ensure that decisions about policy and services are subject to much more openness and transparency, with strengthened public rights to information, and that decision-making boards are made up of people who represent the public interest, rather than private interests. Statutory bodies such as NHS Trusts should remain public and not be transferred to social enterprise, academy or other non-public status. Statistical data should not be manipulated for political advantage.
8 Staffing. Restore the ethos of public service, respect for staff as public servants and recognise workforce as one of the most important issues for the NHS and a major victim of policies implemented in recent years. Involve professional bodies and unions in national and local decisions about safe staffing levels. Commit to safe staffing levels, protected professional status, substantial investment both now as a catch-up and, in the future, commit to training and the means to benefit from it, to ensuring that all staff who make up the team, whether clinical or not, are given proper terms and conditions to enable them to make their contribution. The loss of real value in pay has added markedly to the undermining of morale. The moral injury, burnout and PTSD suffered by many staff must be addressed – by commitment to respecting health and care staff as valued public servants and by addressing the above.
9 Digital services. Currently the introduction of digital services is widely seen as a cost-cutting exercise rather than as a service improvement. There should always be in-person alternatives to remote or digital care for those who want or need them, and recognition given to the fact that some people will never want them or be able to access them.
10 Use of patient data for secondary purposes (e.g. for research or for making decisions about planning, resources and population health management) must be subject to certain principles such as sole ownership of personal data by the NHS on behalf of patients, safeguarding anonymity, allowing opt-outs, preventing private companies from re-use of data for non NHS purposes.