They said they would defend the NHS. They lied. But then, that’s what parliamentary democracy is all about…
Before the General Election in May, the Tories told us that there would be deep cuts in public expenditure caused by bailing out the banks. But Cameron was adamant that the NHS would be ring fenced along with International Development. It made him sound almost angelic. Both Labour and the Lib Dems argued that nothing should be ring fenced – and Labour said in August 2009 it would cut the NHS budget by £20 billion over four years. You could almost think the unthinkable – that the NHS might at least be relatively safe with the Tories under the Tory cuts regime to come.
We now know that the reason why International Development budgets were to be “ring fenced” is to support the war in Afghanistan. But what about health?
Days before the election, Cameron promised to increase funding on the NHS year on year, fund cancer drugs that were currently denied certain patients on cost grounds and committed himself to NHS staff “who do such an incredible job”. Three years ago, Cameron said, “We will never change the idea at the heart of the NHS – that healthcare in this country is free at the point of use and available to everyone based on need – not ability to pay.” Three months after the General Election it’s quite a different story. We now know just how savage the attack will be.
The NHS budget that the government is “ring fencing” is the budget set by the last Labour government and is £20 billion short of what is needed to maintain existing levels of service and care. Estimates of 20,000 job losses are rumoured on this count alone.
So how is it proposed to cope with this black hole? All 10 strategic health authorities and 152 local management bodies known as primary care trusts (PCTs) are to be abolished, affecting more than 60,000 managers. The NHS in England has set aside nearly £1.7 billion this year for reorganisation – more than seven times what it aims to save on management. The money, held back from the front line, will help pave the way for GPs to take over budgets from managers.
Other details give us an insight into the government’s direction. It has lifted the cap on the number of private patients that a trust can treat while simultaneously abolishing targets, including that for waiting times. This will encourage NHS trusts to use the income from private treatment to subsidise the activities squeezed by the black hole.
Some trusts are already looking at treating up to 30 per cent private patients, enticing patients from wealthy Middle East countries. The NHS Christie Hospital in Manchester has signed a deal with a US private health company called HCA for a new private cancer treatment centre with the profit split 50-50 between the Christie and HCA. Many other trusts are already marketing their services abroad. The consequence of all this will be to lengthen waiting lists, forcing the sick to pay if they can, to jump the queue for treatment.
In another move, Lansley carried out Cameron’s promise to fund the expensive cancer drugs that were previously considered unaffordable. How did he manage this? With sleight of hand, he simply transferred the entire budget of £50 million allocated for personal care at home for the elderly with critical needs, to pour it into the pockets of the pharmaceutical companies. The government wants to make us pay for care in our old age.
While the Coalition’s NHS White Paper puts at its centre the meaningless mantra “there will be no decisions without me” (meaning the patient) the government is rushing to implement its proposals without any consultation or parliamentary consent. In a deliberate move to destabilise NHS workers, Health Secretary Lansley has made a series of crude attempts to make changes on the ground without even putting primary legislation to Parliament.
|Unison NHS march in 2007: Labour laid the ground for the Coalition attack on the NHS.|
Lansley announced that NHS commissioning budgets would be transferred from primary care trusts (PCTs) to GPs. David Nicholson, NHS chief executive, is instructing NHS trusts to act on announced reforms without regard for recent protocols requiring public services to wait until consultation is complete and primary legislation is in place before implementing reforms. Consequently some PCTs, thinking or being told they will be redundant, are already beginning to fold. Where they have not folded, morale has nosedived with consequences for their ability to perform.
Just as Gove is railroading his privatisation of education without parliamentary scrutiny, so Lansley is using the budget shortfall to push the government’s agenda through even though the closing date for comments is not until October (the earliest primary legislation can be put to Parliament). Private companies are lining up to take advantage of the weakness of the current commissioning regime at a time when the government has abolished the targets that were intended to hold them to account.
Attack on skill
So what about Cameron’s swooning about NHS staff “that do an incredible job”? The Council of Deans, which represents all universities delivering nurse education, is hearing “unofficially” (presumably in the same way PCTs are being told “unofficially” what to do) that they are to cut the number of nurses starting training each year from 2011 to 2014 with the aim of reducing the numbers in training by a third. The aim, apparently, is to “change the shape of the workforce” in acute hospital settings from the present proportion of 70 per cent registered and 30 per cent health care support to 40 per cent registered and 60 per cent support worker.
Given the legal requirement that a registered practitioner must delegate whatever a health care support worker does, this will also require legislation and go before parliament before it can be approved. This “reshaping” or deskilling of the workforce was what precipitated the crisis at Mid Staffordshire NHS Trust, where there was an exceptional number of deaths. Crucially, professionals failed to act collectively to maintain standards - this is the lesson for us now.
Far too many people in and around the NHS are convincing themselves that the White Paper represents simply an alternative way of organising our healthcare; that GP commissioning is just a variant on PCT commissioning. Nothing could be further from the truth.
There have been two previous attempts to have GP commissioning: GP fund holding of the 1990s and Practice Based Commissioning. Both were voluntary and both received scant support from GPs, not enough to make it a national system. Now Lansley, in an illiberal top-down decision, is to force all GPs, not just those who want it, into commissioning of services. What does all this mean?
Well, Lansley may be right when he says that GPs know their patients better than anyone. But only those they see. What about the more than 90 per cent of their lists who never come through the door? How will they commission services for them? GPs, of course, will not be able, never mind not be willing, to undertake this work. They came into medicine to save lives, not to save invoices. But United Health Europe will be willing and able, as will Kaiser Permanente, Tribal Group and all the other parasitic foreign-owned purveyors of profit out of illness.
Why this reliance on GPs, and an end to even the initial kind of planning represented by Professor Darzi’s “Next Stage” review? Of the near 40,000 GPs in England, many, a majority, are private contractors not NHS employees. They can therefore be more easily offered money, bribes, to run their little corner of the NHS and entirely ignore the rest.
This is why the government’s focus has been on unravelling the polyclinics in London – the first attempt in 60 years to plan away the under-doctoring endemic in the private contractor system, which has led east London into being a veritable desert of GP practices.
Labour laid the ground for everything the coalition is planning to do to the NHS – as it did with academy schools and the attempt to privatise Royal Mail. The market structures, foundation trusts, even the insertion of US corporations into commissioning and GP consortiums, were all products of Blair’s vision of “public service reform”. So Labour’s “opposition” to the assault on the NHS is hamstrung by its own record.
So what does all this tell us about the future of the NHS? It tells us that capitalism, in a state of absolute decline, has total contempt for the health of Britain’s working class. Its nature is to strive to make profits irrespective of the consequences for workers. Capitalism does not want an ageing working class unless they are prepared to carry on working into old age. Our living longer is a burden for capitalism unless it can make money out of the ageing.
Professionals in the NHS who know what is happening fear that it marks the end of the NHS and the beginning of a private, low-quality health system.
It’s not that the government believes that a market way is a better way to ensure healthcare, or GP provision in east London or anywhere else – it simply doesn’t care about GP provision, or about the NHS, or about our health. It cares only about profit: making it and making sure that everything else in Britain is capable of producing it. A real contribution to understanding what to do about this attack is to understand that, and to understand it quick.
And the only people who can stop this potential carnage are ourselves – workers inside and outside the NHS. After World War II, Britain had a financial budget deficit many times today’s as a proportion of GDP. What did we do? We invested in the creation of a free National Health Service. We also invested in industry through a programme of nationalisation and planning. There is simply no reason to implement Labour’s £20 billion cut unless it’s the smokescreen for the complete destruction of our National Health Service.
Health workers do not have to take this and other attacks on skill lying down. A practical approach in every workplace, using our local knowledge and expertise needs to be applied. Workers in every unit should ask questions about the ratio of registered to unregistered staff, link a safe ratio to patient safety and make the public aware of it, and fight attempts to dilute skill.
They should also attend their union branch and discuss what workers think is needed to ensure safety and quality for patients, fight for that – and make sure the local population knows what the workers think. It starts in the workplace.