Defending the NHS: the real fight has yet to start

On 4 March, 250,000 people marched through London in defence of the NHS. Like so many other anti-austerity marches that have taken place since 2011, there was no idea what to do next. The extra money that came in the Budget the following week was a drop in the ocean: a paltry £100m for GP-led triage in A&E and £325m capital funding over three years for Sustainability and Transformation Plans (STPs) – and then only if they jump certain hurdles. The £2bn promised for social care over three years is non-recurrent and will not meet a growing annual funding shortfall estimated currently at £1.9bn. Social care will continue to be cut, and private care companies will reject more and more the minimal payment rates local councils offer for their services. And within days of the Budget, it was announced that £800m reserves earmarked for mental health services will be used to pay off this year’s hospital debts. Robert Clough reports.

The success of the 44 STPs across England is crucial for the process of re-organising the NHS. The long-term aim is to create an integrated management structure across each of the STP ‘footprints’ or regions which in the short term can slash services sufficiently to keep costs in line with savage funding cuts over the next three years. GP-led Clinical Commissioning Groups (CCGs), over 200 of which were set up under the 2013 Health and Social Care Act, will start to reduce in number. Harbingers of this development are the very recent merger of three CCGs in Manchester and three in Liverpool together with the publication of national guidance on the process in November 2016. That 11 CCGs in the West Yorkshire and Harrogate footprint have agreed to form a joint commissioning group is further evidence of this trend.

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Grinding down the NHS - An attack on the working class

womens hospital

The willingness of the Tory government to drive the NHS into the ground tells us how far the balance of class forces has shifted against the working class over the past decades. Prime Minister Theresa May and Health Secretary Jeremy Hunt are confident that they will face no significant opposition as NHS services are strangled by an unprecedented level of funding cuts. British Red Cross chief executive Mike Adamson has called the situation a ‘humanitarian crisis’ as staff have been called in to assist hospitals and ambulance services. Robert Clough reports.

At a time when there needs to be a massive and militant mobilisation of working class people to defend a service vital for their well-being, Labour-led councils are implementing cuts in social care which will make the crisis worse, and the trade unions are all but invisible. All that is on offer by way of opposition is the ritual of a national demonstration on 4 March – an event that will be tightly managed to ensure it presents no real challenge to the government. Meanwhile more and more people will suffer and die as they are unable to get the care that they need.

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NHS cuts round-up

Save NSH

The wide-ranging attack on NHS services is documented by FRFI supporters from around the country.

STPs and Grantham A&E

Lucy Roberts

In August 2016, it was announced that Grantham and District Hospital Accident and Emergency unit would be closed between the hours of 18:30 and 09:00. United Lincolnshire Hospital Trust (ULHT) has said it does not have enough doctors to staff the department safely while also maintaining services in Lincoln and Boston.

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Fight to save free health and social care

Save the nhs protest

There was no extra money in the Autumn Statement on 23 November for the NHS, despite the fact that it is so obviously in a catastrophic financial crisis, we must now expect savage cuts, with an escalation in rationing services and tightening of eligibility to those that remain. These will be set out in the local Sustainability and Transformation Plans (STPs) that are now being published and whose purpose will be to show how £22bn can be cut from the NHS budget over the next four years. Robert Clough reports.

What is happening to the NHS cannot be explained by Tory ideological hostility to state provision of health care alone. A nationalised health service is the cheapest and most efficient way of meeting the health needs of the working class under capitalism. The ruling class is not opposed to the NHS in principle: it simply regards its level of health care provision as far too generous for the working class. Although it seems that the working class pays through its taxes for the NHS as with any other state service, in fact the worker never sees this money nor has any choice about its deduction. The process obscures the underlying reality: that state expenditure is paid for by part of the surplus value extorted by the ruling class. Taxation is the means by which this transfer to the state takes place, and it reduces the surplus value available for profitable capital accumulation. Furthermore, since most of state health care is directed towards the maintenance of workers who do not produce surplus value for the capitalists, either because they are employed unproductively or because they do not work at all through retirement or disability, there is an added reason for the ruling class to axe it (for a thorough discussion of these issues, see Revolutionary Communist No 3/4: Inflation, the crisis and the post-war boom). The pressure is therefore on: the cost of the NHS must be slashed and slashed again. What will determine the outcome will be the extent of resistance both within and outside the NHS, and this presents a political problem for the ruling class: the popularity of the NHS is likely to generate serious opposition to A&E or hospital closures.

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Hospitals as border control – no to racist checks and charges!

‘Women forced to show passports.’ ‘Photo ID to access care’. The media reported with interest on St George’s NHS Trust’s October board papers,[1] which propose that all women should show their passports at their first midwife appointment in order to prove their eligibility to receive care. Condemned by Labour leader Jeremy Corbyn in Prime Minister’s Questions, the proposal received support from Theresa May, who stated: ‘Where there are people who come to this country to use our health service – and who should be paying for it – the health service identifies those people and makes sure it gets the money from them. I would have thought that would be an uncontroversial view.’ Accompanying editorials and articles argued for the need to ‘crackdown’ on ‘health tourism’ to limit the NHS’ growing debt. The financial crisis in the NHS is not the fault of people needing care. Measures such as those proposed by St George’s Trust will be harmful to the people who do need care, and will ultimately cost more. Even more importantly, they strengthen racist arguments about who should be cared for and who should not, and begin to normalise the NHS charging for care.  

Documents from the south London NHS Trust explain that this is about money – about its growing ‘overseas debt’ (money it spends on care for overseas patients, but does not get back), which stands at £4.6 million. The Trust, like others across the country, already charges women who are ‘visiting’ the UK for maternity care, in the form of a bill given after the birth. They currently get back only 20% of the money they try to collect, working with debt collection ‘partners’ LRC, who have proudly clawed back £380 million for their clients, including the NHS and universities. The Trust proposes to remedy the shortfall by a more concentrated effort to identify women deemed ineligible early in their care and bill them sooner. The board papers claim that the hospital has become an ‘easy target’ for women not ‘eligible’ to receive free care, and goes so far as to argue that they are facing ‘organised illegal activity’, with women from Nigeria paying an agent to organise the trip to Tooting to have their babies for ‘free’ on the NHS. This claim – without any apparent evidence – is reminiscent of comments in 2013 from a central London hospital about a ‘Lagos shuttle’, apparently a flow of women coming from west Africa to give birth.

Strengthening checks and charges

The proposal is not new, but is an attempt to advance the process of charging for care. 2011 saw the introduction by the ConDem government of charges passed on to women classed as temporary migrants or ‘visitors’ – around 50,000 pregnant women each year, one in 14 births, costing approximately £180 million a year. ‘Visitors’ include women who have been trying to make their way through the immigration system for years, whilst provided with devastatingly small benefits and inadequate housing. Unable to work because of restrictive immigration laws, women are then burdened with a heavy debt they simply will not be able to pay. The costs stand at around £6,000 per birth, with additional costs for a caesarean or more complex care. FRFI has campaigned alongside women who have been charged over £10,000. This system of charges has already seen horrendous results – two women aggressively pursued for thousands of pounds following the deaths of their babies, of women avoiding care resulting in the loss of their babies and of women having to borrow money from friends, families and churches each month to try to come up with a plan to ease the constant pressure – phone calls, letters and emails - from debt collectors. These bills not only cause constant stress, worry and poverty, but are finally used to deny future immigration applications.

An impossible proposal

Healthcare bodies and charities have explained that charging women is likely to ultimately cost the NHS more. If early, regular and quality care is not provided it increases the potential need for complex care around birth and specialist care postnatally.[2] Women will avoid or delay accessing care, as the current system of charging has already proven. Doctors of the World, a charity providing clinics and support for refugees and migrants, has reported that 75% of women relying on their clinic had not accessed antenatal care from the NHS when they needed it. The proposal can only make this situation worse.

So if the money will be difficult to collect and the proposal costly and harmful, why has it come about now? We are seeing yet another intensification of racist checks and charges which make the country ever more hostile for migrants and refugees. St George’s is candid – its overseas patient team will work ‘in liaison with the UK Border Agency and the Home Office’, to ‘further screen’ women. Health service staff are increasingly being expected to play the role of border guards. Despite attempts to suggest this will not impact on access to care, the board report is littered with phrases such as ‘overseas visitors who are accessing NHS who are not entitled to treatment’. This is simply false; all patients are entitled to treatment. Some have to pay – but this distinction is too often left out, leaving repeated suggestions that pregnant women and patients are not entitled to be seen. The Department of Health and the Cabinet office are already developing national guidance that is ‘likely to advocate routine presentation of proof of identity and eligibility’ for NHS care more generally, including A&E and ambulance services. The 2014 and 2016 Immigration Acts have set the legal framework for the further charging of migrants and expanded the category of those who may face charges. The Department of Health supported the 2016 Act by encouraging more aggressive pursuit of charges, and a spokesperson has said they are looking ‘forward to the results’ of St George’s ‘pilot’.

This is at a time when further cuts are being forced on an NHS in dire financial straits. FRFI has reported on the savage cutbacks, creeping privatisation, bursary cuts and dangerous contracts for junior doctors.  The sums raised by those talking about overseas eligibility are negligible in comparison to the payments made to the private finance initiative (PFI) schemes – private debt schemes – which cost the NHS £3,700 every minute, about £2 billion a year. The endless media stories blaming everyone but the system itself distract attention from the real issues while charges and changes are pushed through. UK director for The White Ribbon Alliance for Safe Motherhood, Brigid McConville, said of maternity charges: ‘It’s the perfect storm for the NHS totally undermining preventive care […] One of the biggest fears is that this is test to get mechanisms in place for charging through the backdoor. Currently it’s for migrants, but who next?’

The intensification of state racism is not confined to health care. The proposal comes at a time when schools are sending letters to parents asking for identification documents.  The week following the release of the board papers saw small numbers of refugee children arriving in Britain, only for their ages to be questioned in a torrent of racist media coverage. Conservative MP David Davies was ridiculed by health professionals when he called for their teeth to be checked to determine their age, but the idea of refugees divided into those who need support and those less deserving remained. Just as charging for health care has been shown to be a bad solution even in cost terms, the idea of ‘eligibility’, of those who deserve care and those who are trying to cheat the system, is being strengthened. We argue against these false distinctions and against racism in all forms. Health and education staff are increasingly being expected to play the role of border guards, which must be opposed by those giving and accessing care, whether we are affected or not.

Rachel Francis

[1] www.stgeorges.nhs.uk/wp-content/uploads/2016/10/Trust-Board-Public-PDF-Oct-16-1.pdf 

[2] Royal College of Midwives, Doctors of the World