I’m embarrassed to admit, that I used to dismiss talk of the ways the NHS was changing. I’d read a few things, but never really understood what it all meant. I never really grasped the true nature of the health service, its history and the way it is being altered today. I shrugged off talk about private companies taking over, and counter-argued with the fact that the population was growing, ageing, and as a result the way we funded its care needed to change.
But for the past 18 months I’ve covered medical politics for a number of titles, including the New Statesman, Open Democracy, and others. It’s been a fascinating, often painful education. I have met with nurses, doctors, academics, politicians, campaigners, patients and concerned members of the public, who have spelled out what is happening to our NHS.
The other day I had a particularly sad conversation, with a nurse I was interviewing for a feature. He described the death of what he called a “moral economy” among NHS workers. He said: “There was almost a family environment in hospitals before. That’s been taken away; the market has ripped the heart and soul out of the service”.
In 2015 we face a lot of big issues as a country – low productivity, public expenditure which well outstrips our national income, environmental challenges, the need to find a fair balance on immigration and so on. They’re all important, but I’m not expert enough to make any big statements on them (I know, it’s never stopped me before). The thing I do know about is the NHS, and I want to share some of that with you, because I think it matters.
I am not arguing that the NHS isn’t in need of reform. The population is living longer, the middle class has swelled, drugs have improved, as has our understanding of them, and the level of care we can now offer for erstwhile untreatable conditions is frankly miraculous. These are truths, thankfully, that most developed countries face, with the downside being that it all costs more.
But for every truth about the NHS, there are plenty of myths. The NHS is not, as some would have us believe, a huge drain on our resources. We spend less as a percentage of GDP on healthcare than most developed nations (well behind France, the Netherlands, Germany, Austria, Denmark, Japan, Norway and Spain, and a drop in the ocean compared to the US). And considerably less of this as a proportion of the budget is spent on administration than in most systems globally, because as a unique national public body the NHS can make savings on procurement, financing, borrowing and workforce planning that more fragmented systems are unable to do.
As a public service which treats people equally, the NHS alleviates our money worries when we are sick, regardless of how rich we are. It employs some 1.2 million people, generating billions of tax revenue through the infinite multiplier factors of income tax, money spent in the shops, and preventing people from becoming economically inactive by getting them back to work.
The NHS is often maligned for being an archaic, inefficient, wasteful bureaucracy, desperately in need of reform, unable to cope with the modern world. The solution pushed by pro-privatisation devotees like Oliver Letwin (in charge of formulating Tory policy), David Cameron and Andrew Lansley, is that by opening the door to the private sector you bring the efficiency and “can-do” attitude to public services that the directors of profit-driven companies get out of bed crossing their hearts with every day.
Now, cast your mind back over the last five years. Do you recall an ongoing thread in the certain parts of the press: that the NHS is at breaking point, desperately in need of reform, unable to cope with the modern world? Well many argue that that’s no coincidence.
Whether or not the press is complicit is a long conversation. But the fact is that an army of PRs is out there, fanning those flames, highlighting every little flaw of the NHS, its practices, and its staff. And it all boils down to one simple message: ‘The NHS needs to change’. Another fact is that a very powerful set of parliamentary lobbyists have been working tirelessly, hand-in-hand with the PR companies, to push the change that their private healthcare clients want to see.
Putting aside accusations of cronyism (billions of Pounds’ worth of NHS contracts have gone to these companies, many of which are Tory donors), let’s take the government on its word that it believes private health can save the NHS. I would argue that while the privatisation model is flimsy at the best of times (the rail networks, utilities for example), it is absolute madness when it comes to healthcare. Healthcare is not a business; patients are not customers.
The flaws in the privatisation model lie in the key distinctions between healthcare and other ‘markets’. Unlike in other commercial industries, every time a new company enters the healthcare marketplace, the contract needs to be monitored and overseen by a trust, for safety concerns etc., which costs time and money. And if it then transpires that a private company isn’t fit to run a service, ward, or hospital, it’s the publically funded trusts which have to pick up the pieces.
The most potent and depressing example of this came in January this year, when the first privately-run NHS hospital, Hinchingbrooke, was abandoned. Circle, the company that had won the contract, just three years before, had walked away, disappointed at the lack of profits. That mess is now in the hands of Cambridgeshire and Peterborough NHS Trust. (http://www.bbc.co.uk/news/uk-england-cambridgeshire-30740956).
This is just one example of the hidden costs of outsourcing – particularly high when it comes to healthcare – which advocates of privatisation always fail to mention.
On a national level, it’s a false economy to say that you can make savings by outsourcing healthcare, not just because of the costs when things go wrong. The cost of running an internal market is huge. This has been estimated at a minimum of £5bn annually, and is probably more like £10bn; all taxpayer money which could and should be spent treating patients.
And on an individual level, health problems are seldom isolated, particularly in older people, so patients as opposed to customers often need integrated care. In the old days if a patient in a hospital needed a host of treatments, it was a case of convening different colleagues by sometimes going and knocking on their door upstairs. In a fragmented system, with competing companies treating an individual patient, this will be far more complex, and require greater administration and money spent by trusts to facilitate.
I would love to blame an increasing prevalence of commercialisation and marketisation solely on the Tories. But the fact is that these forces have been systematically introduced into the health service since the early 90s, and ramped up under New Labour, which also saddled the system with PFI debts that are now crippling some trusts. Anyone who has read my work, particularly in the New Statesman, will know that I have been extremely critical of the Labour Party for this and other aspects of its policy.
But the phenomenal game-changer was the Health and Social Care Act 2012 (http://www.legislation.gov.uk/ukpga/2012/7/contents/enacted).
Pushed by the Conservatives and supported by the Lib Dems, the Health and Social Care Act did many things to dramatically alter the NHS. Despite the government’s pre-election promises of no top-down reorganisations, to reduce red-tape and streamline the service, the Act:
– Created NHS England, a huge bureaucracy with a staff of around 10,000.
– Introduced clinical commissioning groups, clinical support units, Health & Well-being boards.
– Created HealthWatch, Monitor, the Care Quality Commission and numerous other bodies to manage the new NHS. In short, 87 new organisations full of bureaucrats.
– Required a reorganisation which cost (a minimum of) £3bn.
But most crucially, the Act contained new regulations regarding commissioning. This was the kicker. These regulations, under Section 75 of the Act, made it mandatory for all new contracts to be offered out to the private sector. At the time many warned about the dangers of this: private companies always ‘cherry pick’ public sector contracts, taking on the most lucrative and avoiding like the plague the type of costly, risky contracts such as A&E that don’t offer much potential for profit.
This then leave NHS trusts by definition running less efficiently (playing into the hands of the ‘public bad, private good’ lobby). This is because they are saddled with the riskier, less “profitable” contracts which a public service must provide even if private companies won’t touch them with a bargepole.
A few figures, so you don’t just have to take my word for it. Pre-Health and Social Care Act, in 2010/11, £291 million worth of NHS contracts was awarded to private companies. In 2014/15, this had risen to £9.6 billion – itself a 500% increase year-on-year. (It’s all on here http://www.nhsforsale.info/).
Compounding this, the Health and Social Care Act requires by law that trusts must spend money administrating each tender process, even if they are not bidding. This is money which they would rather spend on treating patients, not refereeing bidding wars and subsidising the profits of private companies, (by the way, whose parent companies are often based off-shore to reduce their tax exposure).
If they are bidding for a contract they come up against private companies with teams of corporate lawyers to pick through the colossal bureaucracy involved. When a company is dead-set on winning a contract, generally it will. The taxpayer money the trust has spent on competing (often hundreds of thousands of Pounds) goes straight down the drain.
It’s the steady realisation of a fear that many have expressed since long before the Health and Social Care Act: that the NHS will become nothing more than a ‘Kitemark’, a fancy badge of respectability for companies to stick to their branding, leaving the service little more than the administrator of a commercial market.
The sad reality for medical staff, is what was described by the nurse I quoted at the beginning. With every new contract that goes out, be it in clinical services, facilities, administrative, catering or whatever, this fragmentation, the grinding down of the “moral economy” he described, increases. Having staff on different pay, contracts (often zero-hours), Ts&Cs and pensions from each other created tensions and diminishes team spirit.
So why am I going on the mother of all rants now? Well there happens to be an election tomorrow.
The main theme of the Conservative election campaign has been ‘Labour destroyed the economy, we fixed it’. But mark my words, within six months, the rhetoric will be back to, ‘We’re still in a mess, and need to slash more from public spending’. Austerity has had many effects on our economy, even our psyche. One of these has been to squeeze the NHS.
The pincer effect of cuts to local authority social care budgets and squeezes on GPs have driven more people into emergency care, and meant that people are sicker when they arrive. And at the other end, the sickening factor of ‘bed block’ – where cuts to community social care mean that people have to remain in hospital, clogging up wards – puts the vice on A&E wards from the other side.
With the big prize of the Health and Social Care Act now in place, private companies have the legal heavy hand they needed. And with staff morale ground down to a raw nub, trusts under so much financial pressure that they will be forced to get contracts off their books just to balance them, and a public primed to believe that the NHS cannot cope, the service is five years away from being morphed entirely, into a purely notional, administrative framework for a private/insurance system.
Labour may not be perfect, but there is one key difference. Ed Miliband and Andy Burnham have pledged to repeal the Health and Social Care Act. Labour has said that it wants to limit the role, and profits, of private companies circling around the NHS, and has already allocated the funds it would use to hire 20,000 more nurses, 8,000 more GPs and 3,000 more midwives, to take the immense pressure off a workforce at breaking point. This wouldn’t undo everything – there would still be a huge amount left to do to purge the system of these cancerous forces. But it would at least remove the legislation that reads as a death-sentence to the role of the NHS as a service for the people, by the people.
The NHS is unique in the world. A symbol of union and equality when we are at our most vulnerable; of the benevolent role of the state, of a notion of unity between humans. It was born in 1948 out of the immense suffering our parents and grandparents had endured in the war, and has nurtured generations from cradle to grave ever since.
I never used to appreciate how lucky we were; I shrugged off the fears as nonsense. I hope somewhere in among this, I have explained why I no longer do, and why I think tomorrow matters.