The winter crisis in the NHS has continued into the spring. Bed occupancy rates were at their highest levels in February, surpassing the 95% of December 2017. Waiting times in A&E were the longest since records began as were trolley waits for patients requiring a bed. One hospital reported the death of a man who had sat in a chair awaiting admission because all the A&E trolleys were in use. Conditions of work continue to deteriorate. More and more hospitals have been setting up private companies to employ non-clinical staff in a VAT scam which will mean new staff will be denied nationally-agreed salary levels. NHS unions had offered no effective opposition to this development, and now they are being presented with a pay offer which will amount to a further pay cut over the next three years. Robert Clough reports.
Demand for NHS treatment continues to rise while the number of hospital beds continues to fall. By autumn 2017, the NHS England’s winter plans were based on 7.3% fewer acute beds than in 2010 while facing emergency admissions 14.5% higher. While the number of emergency admissions peaked in January 2018 at 525,897, 6.8% higher than in January 2017, February recorded the highest level of bed occupancy of 96%. This was not just because of the rise of emergency admission but because patients were more ill: on 20 November, 43,655 patients had been in hospital for more than seven days, with 16,939 for more than 21 days. By 4 March, the latest date for which data is available, the figures had risen to 48,304 and 18,666 respectively with just under 100,000 beds available across the country.
In Nottinghamshire the strain was so great that on 16 February, the Greater Nottingham Transformation Partnership placed itself on a so-called ‘black alert’ for an entire weekend. The partnership, a collective consisting of all health and care organisations in the area, was placed three times on Operational Pressures Escalation Level (OPEL) Four – the most severe rating for health organisations. At times the number of patients attending A&E daily in Nottingham University Hospitals rose to 500 – the department has a capacity of 350. The crisis continued into late March with all non-urgent operations cancelled until the new financial year in an effort to ‘reset’ the partnership.
The pressures on A&E had their inevitable consequence when a patient died in Northampton General Hospital on 8 February in an incident the hospital’s medical director attributed to the ‘dangerous overcrowding’ of the hospital’s A&E department. It was dealing with 400 emergencies a day, 30% more than the equivalent period in the previous year, and the hospital had been on the highest level of alert for three successive days.
Across England, the number of occasions on which there was a breach of mixed sex accommodation rules doubled between November 2017 and February 2018. This is a strong indicator of the pressure on beds: mixed sex wards were phased out by 2010. The proportion of patients seen in A&E within four hours in February was 85%, but just 76.9% for major A&E units, both figures the lowest of the winter period, and indeed the lowest on record.
Financial crisis
Despite running every possible financial scam in the book – ‘magic bean-counting’ – there is no hiding the fact that NHS England’s financial deficit continues to grow:
- • More than one-third of Clinical Commissioning Groups are forecasting a year-end deficit; it is expected they will carry forward a debt of £500m into 2018/19.
- • In February hospitals’ combined deficit was expected to reach £931m at the end of the financial year compared to £791m last year. This is after the £1.8bn Sustainability and Transformation funding has been distributed – a means of conjuring away the majority of the real deficit which the Nuffield Trust estimates is £3.7bn.
- • 58 hospital trusts have had to revise their forecast deficits upwards. One of the most extreme is King’s College NHS Trust, whose deficit has increased from £38.4m to £92.9m; Health Service Journal reports it may in fact reach £120m. King’s will need some £250m in Department of Health loans until the end of the financial year, by which time it will owe £677m. It is effectively bankrupt, but its predicted deficit is exceeded by that of University of North Midlands Trust in Staffordshire, which is likely to reach £144m. Both trusts had taken over smaller hospitals in financially disastrous positions and are now reaping the consequences.
- • Trusts failing to meet their financial control targets cannot receive any Sustainability and Transformation funding. In order to keep going, they have to borrow money from the Department of Health and repay it with interest. Over the last three years, interest payments have totalled £183m (£85m in 2017/18); interest rates for trusts in special measures are a punitive 6%. These are short-term loans; on longer-term loans 172 trusts paid £173m interest in 2016/17 compared with 167 paying £117m the previous year.
The government trumpeted the £337m extra revenue allocated to the NHS in the 2017 budget, but all this did was to reduce deficits built up in preparation for winter. Coming so late in the day it would not allow any increase in the number of clinical staff; hospitals had already paid upfront for temporary or agency staff as part of their winter preparations. A further £267m in January 2018 went the same way.
Magic bean-counting
‘Magic bean-counting’ can involve weird and wonderful tricks of accountancy in order to make hospital bottom lines appear less woeful, and allow them to gain access to extra funds. Hospitals are paying management consultancies to revalue their estates in a way that assumes services could theoretically be consolidated to a cheaper ‘alternative site’. This gives a lower ‘book value’ within the accounts, which reduces the charges they have to pay on their estate. For some trusts this wheeze is worth £6m for their bottom lines, although there is no extra money generated, and indeed costs them in cash terms to pay the consultants. However, NHS Improvement has instructed trusts to use this accountancy trick if it improves their bottom lines.
Another magic bean-counting method is far more insidious. It involves foundation trusts establishing private subsidiary companies to employ estates and other ancillary staff and even take over the hospital’s estate as a whole. As of mid-February, 19 providers have set up such companies, and 16 more are considering the move. Part of the aim is to take advantage of obscure VAT rules using tax avoidance advice from the likes of KPMG. Even the Department of Health has joined in, setting up a private company to implement savings following the advice of EY which cost £2m. In its former guise as Ernst & Young, EY pioneered public sector tax avoidance schemes. Although existing staff will be transferred on existing NHS pay and conditions, subsidiary companies will be able to employ staff at lower rates and with poorer conditions. Those trusts which have also transferred their estate such as Northumberland Tyne and Wear could use the company to sell parts or all of their buildings either outright or on a lease-back arrangement. In the cases of Gloucester Hospitals and Wigan Wrightington Leigh, over 800 staff are involved in such outsourcing while across the country an estimated 30,000 NHS staff face transfer in these scams.
More pay cuts
Unison indicative ballots have shown more than 90% of workers back strike action against these privatisation plans in Wigan and Calderdale: they deserve our full support. They also need a fighting spirit which is completely lacking in the trade union leadership. Following Chancellor Hammond’s announcement last year that the public sector pay cap has been abolished, trade unions and the Department of Health have been in negotiations over pay. Yet in reality what is on offer – a 6.5% increase spread over three years – is not a pay increase for the majority, but yet another pay cut as inflation is likely to run at an annual 3% over the period, around 9.3% overall. The offer follows the average 14% real-term pay cut since 2010 for NHS staff (including nurses and paramedics), equivalent to about £2,000 per year. However, unions are recommending acceptance of the pay cut to their membership following the release of the formal offer on 21 March; only the GMB is asking members to reject it.
NHS England’s chief executive Sir Simon Stevens described February as ‘the most pressurised month the NHS has seen in its nearly 70 year history.’ There is no sign that this pressure will end as NHS spending per head of population will continue to fall under the Tory government’s spending plans. The trade unions have shown no willingness to fight back: eight years of continuous pay cuts is testimony to this. What is needed is a movement which unites NHS workers with other sections of the working class who depend on the NHS in a battle which will not capitulate to the threats of the Tory government or the ruling class.
‘Hostile environment’ for migrants – a death sentence for some
When Theresa May as Home Secretary announced in 2013 the establishment of a ‘hostile environment’ for immigrants, the possibility that this might amount to a death sentence for some was not immediately apparent. However, with the requirement from October 2017 for hospitals to check the residential status of patients we can now see that it can be. Albert Thompson, resident in the country for 44 years, was denied radiotherapy treatment for prostate cancer by the Royal Marsden cancer trust because he does not possess a British passport nor other evidence that he is entitled to NHS care. He could receive the prescribed treatment – provided he paid £54,000 in advance.
It was shameful that the Marsden acted as immigration officials for the government, shameful that it denied the treatment, shameful that since then the trust has said that it really wasn’t necessary for Thompson to receive the treatment yet. Labour leader Jeremy Corbyn has written to May raising Thompson’s case: there are clearly many others in Thompson’s position. However, May refused to take any action, saying it was down to the hospital to assess whether the case was an emergency. That Thompson will die unless he receives the treatment is evident; that the clinical staff at the Marsden did not take a stand on the Hippocratic injunction to do no harm is shocking, all the more so when it was revealed the Marsden had received £210m in private patient income over a two-year period. The overall impact of immigration checks on the health care of migrants is impossible to quantify: it is evident though that many will avoid hospitals unless it is an emergency. This means that pregnant women will miss out on antenatal checks and therefore be more likely to suffer complications during pregnancy.
Fight Racism! Fight Imperialism! 263 April/May 2018
