NHS: back on the precipice

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The NHS in England is again on the brink of a winter crisis. The extra money promised in November’s Autumn Budget has been calibrated to obtain electoral benefit for the Tories while keeping a chokehold on NHS spending. Key programmes to prevent the sort of disaster that threatened the health service last winter have failed. Bed occupancy rates are nowhere near safe levels. Reductions in delayed transfers of care – where a patient is medically fit for discharge but neither home care or social care are in place – are nowhere near target. Emergency admissions continue to rise. Hardly any A&E departments are meeting the 95% mark for treating patients within four hours of arrival; many are falling below 90%. Ambulance response times are deteriorating. Financial savings are nowhere near what is demanded despite a 1.7% improvement in productivity. 80% of Clinical Commissioning Groups (CCGs) are considering rationing operations. Behind this lies the determination of government to reduce real-term funding of the NHS as part of its overall attack on the working class. Robert Clough reports.

Chancellor Phillip Hammond had already made it clear that the Budget would not include the £4bn increase that think tanks the Nuffield Trust and The King’s Fund were insisting were necessary for 2018/19. Instead he repeated the Tory lie that the NHS had received what it had demanded in 2015. That figure – £10bn – is utterly discredited, but is still trotted out by the government to blame the NHS for its own predicament. The real amount was £4.5bn, most of which was used in 2016/17 to help pay off huge hospital deficits. NHS funding has to rise by 4% per annum to keep pace with the expanding population, the increasing proportion of elderly people, and the costs of new technologies and drugs. The annual increases planned for 2015/16 to 2020/21 were an average 1.1%, but this year was just 0.7%, and in 2018/19 was projected to be 0.4%.

In the end the Budget offered a pitiful £335m to cope with winter pressures this year, and £1.6bn next year. These sums, together with £900m in 2019/20, are ‘exceptional’, and will not be rolled forward. NHS leaders stated that £8bn recurrent funding over this period was essential to maintaining services at their current level. The extra money for this year will already have been eaten up by existing hospital deficits. There was no extra money for social services which face a shortfall of £2.6bn by 2019/20. Hammond has the support of Prime Minister May who early in November made it clear that she would hold NHS England Chief Executive Sir Simon Stevens personally responsible for any winter problems.

With the onset of winter:

  • Bed occupancy remains well over the safe level of 85%. It was 89.1% at the end of June 2017, only fractionally below the 90.2% of June 2016.
  • A&E: The government will trumpet the fact that in 2017 overall performance met the reduced 90% target to treat and discharge patients within four hours. But two-thirds of Britain’s 137 A&E units fell below 90% in September 2017; 30 of these were below 80%.
  • One of the main NHS preoccupations has been to reduce emergency admissions, with a notional target of 5%. In practice emergency admissions rose by 3.4% in September 2017 compared to September 2016.
  • Reducing emergency admissions was one way of tackling high bed-occupancy levels. Another was by reducing the number of delayed transfers of care. This involved giving social services an extra £1bn this year. Much of this was used to pay increased charges rather than increase capacity because of the introduction of the National Living Wage. Instead of reducing the number to 3,500 occupied beds by September 2017, it was still at 5,610 beds.
  • Ambulance response times are deteriorating, with 66.3% of Red 1 calls and 58.6% of Red 2 calls being met within eight minutes – the target for either is 75%.
  • Waiting lists continue to increase, as do waiting times for operations. Overall, 3.83 million people are waiting for treatment, up 3.8% in the year since September 2016, and of these, 418,000 have been waiting more than 18 weeks.

The measures that hospitals are taking to manage this crisis have taken on a bizarre quality: Kingston Hospital borrowed £10m from Lloyds Bank to continue paying its staff, while in Essex, hospitals are looking at Airbnb-type solutions where households offer up spare rooms to accommodate discharged patients in return for up to £1,000 a month. Meanwhile, hospital overspending against control totals amounted to £1.15bn at the end of September 2017, despite £630m emergency funding. The real deficit at the end of the financial year will be nearly £4bn, worse than in 2016/17; it will absorb much if not all of the extra money promised for 2018/19.

There are two ways that the NHS can manage the situation. One is to force its staff to work even harder, the other is to extend rationing. On average, NHS staff are £2,000 a year worse off than in 2010 as a result of successive wage freezes. BBC figures show how staff numbers have risen by 6% between 2013/14 and 2016/17, but emergency admissions have risen 10%, ambulance calls by 15% and diagnostic tests by nearly 20%. Staff are working harder, for longer hours. Health Secretary Jeremy Hunt announced the end of the pay freeze for NHS staff in October 2017. Hammond said that if talks with the unions about changing pay conditions bore fruit as part of a wage rise, he would ‘protect patient services by providing additional funding for such a settlement.’ Careful phrasing which stops short of a guarantee to cover the entire cost.

The other way is to ration services. Four in five CCGs are considering reducing the number of operations they will pay for in some specialties; over half may introduce eligibility criteria for receiving treatment such as smoking status or body mass index. These measures will penalise the working class and poor.

In a desperate effort to bully the NHS into doing the impossible, NHS England has ordered that no patient is to be required to lie in a corridor for hours, and that patients must not wait more than 15 minutes outside A&E. Hospital managers called the instructions ‘la-la land thinking’. NHS England chair Sir Malcolm Grant stated the inevitable outcome of the budget: ‘We can no longer avoid the difficult debate about what it is possible to deliver for patients with the money available.’ Rationing will become national policy rather than a local phenomenon. It is up to us whether they are allowed to get away with it.

Fight Racism! Fight Imperialism! 261 December 2017/January 2018