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.
The crisis has worsened week by week over the winter period. The number of A&E attendances has reached critical levels, with 52 hospitals having to divert ambulances elsewhere at some point during the second week in January, compared to 39 in the first week and 27 in the same week of 2016. In addition:
• 68 hospital trusts – 45% of the 152 in total in England – declared an alert (so-called OPEL Levels 3 or 4) during the same week, up from 65 the week before;
• on Monday 9 January, 61 trusts issued an alert, the highest number ever on a single day; this included three-quarters of hospitals, 28 in all, in the south of England outside London;
• 15 trusts were on alert continuously for 11 days in a row between 3 and 13 January;
• bed occupancy across England reached 96.4% on Monday 11 January; 15 hospitals were completely full and another 24 had five or fewer beds available for emergency admissions.
The government’s response has been to variously blame the crisis on GPs whose surgeries are not open 8am to 8pm, on inefficient hospitals, and on patients who should have gone to their GP instead of A&E. Jeremy Hunt claimed in parliament on 9 January that 30% of A&E attendees should not be there, and that the four-hour A&E target really should apply only to the other 70% with urgent needs. Like a true coward, he ran away from reporters who demanded to know whether that meant the four-hour target would be watered down. He himself had taken his children to A&E in 2014 because he could not get a GP appointment when he wanted one.
In reality, GP services are unable to cope with the demand, especially in the winter period. It is estimated that more than 90% of all NHS patient consultations take place in a GP surgery – about 340 million a year. Studies show that not only are the number of GP consultations rising (13.7% between 2007 and 2014) but that their duration is increasing while the number of GPs per head of population is falling (60.9 GPs per 100,000 patients in 2007 to 60.6 in 2014). Now absolute numbers are falling: latest figures show that the number of GPs including trainees in September 2016 was 34,495, 96 down on the figure for September 2015. Practices are triaging patients for emergency appointments, with two week wait-times the norm for routine appointments. It takes only a tiny fraction of those unable to get a GP appointment to turn up at A&E instead for the service to be overwhelmed. Hunt’s claim is a distortion of what NHS England director of acute care Professor Willett had argued – that 30% of A&E patients would be better cared for elsewhere in the system. The issue is that they can’t be because there is no spare capacity.
Record levels of bed occupancy have meant that patients needing to be admitted as emergencies have had to endure lengthy trolley waits while waiting for a bed to become free – 18,000 in the first week in January waiting more than four hours, and 485 more than 12 hours, treble the number for the whole of January 2016. The number of elderly people waiting for more than 12 hours in A&E has doubled over the past two years. Between 1 and 3 January, three patients died in Worcester Royal while waiting for a bed, including one patient who had been on a trolley for 35 hours. One patient was left on a trolley for 54 hours.
The pressures in A&E have a knock-on effect on the emergency ambulance service. Ambulances have to queue outside hospitals until it is safe to hand over their patients because A&E departments are overflowing: 6,072 out of 9,242 handovers in London alone in the last week of December 2016 took more than the 15 minutes allowed; such delays totalling 1,727 hours. This means that there are insufficient ambulances available to attend emergencies: in early December, the London Ambulance Service was only able to reach 58.8% of top-priority Red 1 calls within the required eight minutes – the target is 75%. In Greater Manchester ambulances have had to wait for up to ten hours to hand over patients. Across the country ambulance services have failed for 18 months to meet the target response times for Red 1 calls. The National Audit Office reports that half a million ambulance hours were lost on ambulance handovers taking more than 30 minutes at A&E departments in 2015/16 – the equivalent of 41,000 12-hour ambulance shifts. The situation has only got worse since then. West Midlands ambulance trust is seeking millions of pounds in compensation for such delays.
Record bed occupancy levels and rising numbers of emergency admissions – up 4% year on year – are forcing the cancellation and postponement of tens of thousands of operations. Hospitals are now reporting that they are routinely postponing cancer operations. The Royal College of Surgeons reports that last year 193,406 people each month did not get surgery within 18 weeks of referral, almost double the figure four years ago of 105,427. Comparing November 2016, the latest month for which figures are available as we go to press, with November 2015:
• the number of urgent operations cancelled was 83% higher;
• the number of patients who had had to wait more than the target 18 weeks for their treatment went up to 354,795 from 251,406;
• waiting list numbers had risen to 3.75 million from 3.31 million.
Five hospitals were regularly unable to fill more than 80% of the planned daytime nursing shifts in October 2016; 79 were unable to meet 90% of their requirement. Many trusts are using health care assistants to fill the gaps.
May has made it clear that there will be no more money for the NHS. None was forthcoming in the Autumn Statement last November, and she knows she can weather any storm in a teacup whipped up by Jeremy Corbyn and the Parliamentary Labour Party. NHS Chief Executive Simon Stevens described her claim of having given the NHS a more-than-requested £10bn extra a year as ‘stretching the truth’ when he appeared before the Health Select Committee on 11 January, the furthest a civil servant could go without calling it a lie. Half of the real sum of £4.5bn has been allocated for 2016/17; it means that there will be no extra money available for 2017/18 through to 2019/20 after allowing for inflation, while the overall population will increase by 3% and the number of over-75s by 15%.
The strategy of the government is to rely on NHS management to use the local Sustainability and Transformation Plans (STPs) to force through the cuts in services that are necessary to keep within the reduced budgets. There are 44 such plans for 44 arbitrarily-defined geographical areas across England. Yet they are just fantasies: Health Service Journal has analysed 11 of the 44, together with their unpublished detailed finance, workforce and efficiency plans, and found that collectively they forecast:
• a reduction of around 4.1% in the number of emergency hospital admissions over the four years from the end of 2016/17 to 2020/21 when they rose by more than that (4.8%) in the 12 months to October 2016;
• a reduction of 0.8% in the number of A&E attendances over the same period when they are rising at 3.7% annually despite attempts to limit this through referral management schemes;
• rises of just 1.0% in planned hospital admissions and 2.6% in outpatient appointments when the predicted increases for 2016/17 alone are 3.1% and 4.3% respectively.
All this is supposed to be achieved with fewer staff, in particular a 2.3% reduction in registered nursing posts. With bed occupancy currently running at 96%, STP proposals to axe thousands of beds over the next four years can only be achieved by severe rationing of hospital operations. The notion that it is cheaper to treat more patients in the community rather than in hospital has never been proven, and again could only be achieved by restricting treatment and then by cutting wages for health care workers and worsening their work conditions.
Such rationing is now increasingly widespread. Three Clinical Commissioning Groups (CCGs) in the West Midlands have reduced eligibility for hip and knee replacements explicitly to save money. The revised criteria require that the ‘patient’s pain and disability should be sufficiently severe that it interferes with the patient’s daily life and/or ability to sleep’. The CCGs say that 350 fewer operations will be needed, saving just over £2m a year. Richmond CCG has also proposed rationing as a way to reduce costs. It is consulting about rationing hip and knee operations, cataracts and hearing aid provision, and (now an increasing favourite) limiting treatments for obese patients and smokers. 37 CCGs (out of 220) have set cost restrictions on NHS Continuing Healthcare funding. This pays for ongoing care for adults who are assessed as having a primary medical care need to enable them to continue living at home. It is estimated that this affects 13,000 patients who could be forced to move into a residential home as a result.
Resistance to the STPs needs to be built from now. Campaigns against hospital and A&E closures, service transfers and rationing need to start now. 1.2 million people work in the NHS, many of them low-paid nursing and support staff, and they need to play a leading role in this resistance, boycotting any attempt to implement the STPs or to introduce rationing. This will not be organised through the trade unions or the Labour Party: their priority will be to organise pointless demonstrations and prevent any real struggle so as to ensure a Labour government is returned in 2020. It is the working class who will suffer from the destruction of the NHS, and it is the working class which must lead the challenge and start to change the balance of class forces.
Fight Racism! Fight Imperialism! 255 February/March 2017
