Mawkish sentiments marked the 70th anniversary of the foundation of the NHS. Prince Charles, who has never used the NHS to our knowledge, preferring private queue-jumping and fawning luxury, was trotted out to pay tribute to ‘one of our country’s greatest treasures’. Celebrities recounted how their lives had been saved, how much they owed the service, in newspapers like the Daily Mail, otherwise renowned for undermining the NHS at every opportunity. Prime Minister Theresa May thanked ‘one of our nation’s most precious institutions’– although her government has been responsible for bringing the NHS to its knees. The Archbishop of Canterbury opined that the NHS was ‘the most powerful and visible expression of our Christian heritage’. The government, aware of the unpopularity of a decade of cuts in real-term funding for the service, used the occasion to offer an increased level of funding over the next three years – although still well below what the NHS needs. Hannah Caller and Robert Clough report.
Staffing crisis
The continuous cuts in funding have resulted in a staffing crisis. In England alone, there are almost 40,000 vacant nursing posts. Across the whole workforce, the gap is closer to 100,000 people. Two years on from the announcement that nursing and midwifery bursaries are to be removed, applications to nursing degree courses have fallen by a third in England. The number that will begin training in September 2018 has dropped by 12% compared to 2017, which means a decline of 16,580 since March 2016 (the last year students received financial support via a bursary). The fall in the number of mature students applying is even greater, 16% fewer than the previous year, and 40% fewer than in June 2016. The independent NHS Pay Review Body predicts that this staffing gap will persist until 2027 unless immediate action is taken. Patient care will be adversely affected for much of the next decade.
In 2016, nearly three-quarters of all medical specialities had unfilled training posts, with dozens of hospital specialities facing year-on-year difficulties: recruitment of doctors and the number of applications to British medical schools in 2017 decreased for the third year in a row. In 2017 alone, £3bn was spent on locum doctors to fill the gaps.
In 2017, 415 GP practices closed, and it is estimated that between 618 and 777 are likely to have to close by 2022. Funding for General Practice remains £3.7bn below the 11% target of total NHS funding outlined in the GP Forward View. This estimated that 3,250 doctors need to enter training per year – only 3,157 started in 2017. Trainee GPs are now being offered £20,000 to work in certain parts of England that have difficulties recruiting and where there is a shortage of doctors. The British Medical Association suggests bigger incentives may be needed such as paying off part of student loans for trainees who enter general practice.
With the uncertainty created by Brexit, applications from EU clinicians to work in Britain have fallen by 93%. The Royal College of Physicians has issued new guidelines which include the phrase: ‘Patients must get used to nurses and other less-qualified staff doing much of the routine medical care in hospitals…’
Migrant labour
Migrant labour built the NHS, from domestic and portering staff to doctors and nurses, many of whom worked in the least attractive specialities and geographical areas to fill posts that British trained staff would not take up. Black and minority ethnic doctors are still more likely to suffer bullying and harassment in the workplace, referral to professional bodies by their employers and other sanctions.
The Tier 2 visa route for immigration by skilled workers from outside the EU, has an annual cap of 20,700. This was imposed in 2011 when Theresa May was Home Secretary. Hospitals have spent thousands of pounds recruiting overseas doctors only to find that their visa applications have been refused. Doctors represent one fifth of all applications to the Home Office for Tier 2 visas. Between November 2017 and April 2018, only 34% of doctors had their visas granted, compared to 45% of other applicants. This period saw over 1,500 visas for doctors rejected despite hundreds of unfilled posts within the NHS. In June, the Home Office, under immense pressure, finally agreed to exclude doctors and nurses from the visa cap that was preventing thousands taking up jobs in Britain.
Mental health services in crisis
Despite the pledge to stop mental health Out of Area bed placements by 2020, 700 people had to be found beds outside their local area in January, 23% up on the same month last year and the highest level since 2016. This may mean patients have to receive treatment hundreds of miles from their homes. The number of hospital beds for people with serious mental health conditions with a consultant psychiatrist present has fallen almost 30% since 2009. Child and Adolescent Mental Health Services are failing most to meet acceptable standards. The number of inpatient beds for people suffering psychosis, serious depression and suicidal feelings, and eating disorders has fallen from 26,448 in 2009 to 18,082 at the start of 2018. Alongside this, the number of mental health nurses has fallen from 46,155 to 39,358, and the number of doctors in specialist psychiatry training, from 3,187 in 2009 to 2,588 in the first quarter of 2018. This makes a mockery of the 2012 Health and Social Care Act that established that there should be ‘parity of esteem’ between physical and mental health. The new Health Secretary Matt Hancock did not even mention mental health issues in his inaugural comments.
Funding
In 1942 William Beveridge said that a comprehensive health service would diminish disease by prevention and cure, and costs would consequently be relatively stable. The first crisis came early in the NHS, in the first winter of 1948 with substantial overspending and alarm at the Treasury. The response was to charge patients for optician and dentistry services, which led to Aneurin Bevan’s resignation and an investigation into NHS costs. Crises have occurred ever since. The NHS Confederation, representative of health care leaders, along with the Health Foundation and the Institute of Fiscal Studies, found that since 2010, under the last two governments, the NHS has seen average annual growth of 1.1% compared to an average of 4% throughout the health services’ history beforehand (a level necessary to cover new technology, treatments and inflation costs). The recent ‘70th birthday’ settlement, involving an increase in NHS funding of £20bn by 2023/24, is equivalent to a 3.4% increase in real terms. But this additional spending will be swallowed up sorting out the shortfalls in services and staff that have accumulated under successive Tory governments.
NHS Improvement, which oversees NHS providers, claims the service is broadly in balance even as hospitals report deficits of £960m. However, a senior Nuffield Trust Policy analyst says the true provider deficit is closer to £4bn and that ‘This hand-to-mouth existence is not a sustainable way to run complex and vital institutions like hospitals.’ The chief cause of the deficit was increasing demand for emergency care. Attendances at A&E departments rose in the year to 31 March 2018, as did emergency admissions, with two effects: diverting resources away from elective care at a cost of £505m and imposing higher costs by using temporary workers to fill staff vacancies.
Waiting lists for elective care inevitably lengthened and at the end of March 2018, 2,647 patients had been waiting more than a year, up from 1,513 the year before. Emergency department targets were also missed and by a wider margin than in 2016-17. While 95% of patients are supposed to be seen within four hours, in 2017-18 the figure fell to 88.4% (from 89.1% the year before). The think tank, the King’s Fund, explained that ‘many NHS organisations are being set annual financial targets they have no realistic hope of achieving, while providers of community, mental health, and ambulance services are effectively underwriting substantial overspends in acute hospitals.’ And this is not to forget Private Finance Initiatives (PFIs): the NHS bill hit £2bn last year, enough to pay for the wages of all qualified midwives for two and a half years. At the Royal London Hospital in east London, the true cost of the new building is £1.1bn, but the PFI cost is £7.1bn, with monthly repayments of over £10m until 2049.
Service reduction – patient safety or rationing
The Hippocratic Oath stands against any measure that stops people seeking health care. Despite this, NHS hospitals now display posters reminding people they must prove their eligibility before obtaining care. Those who are unsure will be scared and stay away. A recent investigation in London found that of 8,894 people attending a London hospital who were asked for two forms of ID, only 50 had to pay for their care. There is no evidence that this policy raises any significant amount of money, especially since those liable to be charged are the least able to pay. It is just part of the ‘hostile environment’ – a completely racist measure. In a gesture of opposition, 20 health workers have returned the special Ebola medals they received from the government for their role in treating those suffering from Ebola disease in West Africa in 2014. One of them, Dr Neal Russell, said:
‘I cannot keep a medal from a government whose policies are directly harming my patients. The human right to health must be restored as the ultimate principle of the NHS. Healthcare workers elsewhere have defended that right for undocumented migrants. Those of us who are now handing back our medals are hoping to achieve the same.’
Currently a 12-week public consultation is underway regarding 17 procedures on the NHS hit list for which NHS England is proposing to cut funding as they are considered unnecessary, some due to lack of evidence of their effectiveness. These 17 procedures are carried out 350,000 times a year; reducing them would save less than 0.2% of the annual NHS budget of around £125bn. This process will primarily boost private sector provision among those who can afford it: Spire Healthcare, one of the largest providers of private health care in Britain, saw a 12% rise in revenue from all self-paying patients in 2017. The poorest people will have to do without.
The NHS needs sustained investment in staff, services and funding in order to meet demand. The internal market, the increasing expenditure on management, the competition and use of the private sector, are all compounding the funding issues and affecting care. Services are being rationed and discriminatory demands for proof of eligibility are commonplace. True celebration of the National Health Service requires a fight for a future of universal health care, free at the point of delivery. We must defend the principle of a health care system that is state-run and financed, as any privatised system necessarily excludes the working class and poor from any chance of adequate health care. In the end however, capitalism will not tolerate an adequate state-run system – only socialism will guarantee that.
Fight Racism! Fight Imperialism! 265 August/September 2018
