The NHS is going through its worst crisis since it was set up nearly 70 years ago. Years of underfunding have had their inevitable consequence. Newspaper headlines tell part of the story: thousands of patients each week having to wait in ambulances before they can be admitted into A&E; A&E departments designed to treat 350 patients a day that are seeing 500 to 700; wait times in A&E that are growing longer and longer while bed occupancy runs at 95%, way above the safe maximum of 85%. The government tells lies about how the service is coping: it does not care that 55,000 patients have had their operations delayed, including many thousands of cancer sufferers. Robert Clough reports.
Although the NHS is financed through taxation, taxes themselves are a deduction from the profits made through the exploitation of the working class. The ruling class is determined to ensure that such deductions are reduced to a minimum: hence the policy initiated by the ConDem coalition in 2010 and continued by the Tory government to choke off NHS funding, ensuring that it fails to meet the needs of the working class. The NHS budget needs to increase in real terms by 4% annually to meet the costs of new technology and drugs, but also because of an ageing population with more long-term health problems. But the average annual increase since 2010 has been just 1.2%, a level which the government intends to maintain until 2021. Whether it can will depend on the balance of class forces. So far the trade unions in the NHS have offered no meaningful resistance, despite a seven-year run of 1% pay caps or outright pay freezes, and constantly deteriorating conditions of work.
Winter 2016/17 had seen the NHS placed under immense pressure: hospitals were repeatedly declaring alerts because they had no spare beds, ambulances were being diverted from one A&E department to another, GP services were unable to cope (FRFI 255, ‘Grinding down the NHS’). The response of the government was to blame anyone but itself: patients for using A&E, GPs for not opening their surgeries, hospitals for inefficiency. In its November 2017 budget, the government grudgingly allocated an extra £335m to cope with the anticipated winter pressures. However, this was almost immediately eaten up by existing hospital deficits. The government has been cooking the books to imply that the NHS can survive on the funding it receives. In 2016/17, £3.1bn had to be found, £1bn of it from the Sustainability and Transformation Fund, to plug the hole in hospital finances, reducing their overall deficit from £2.4bn in 2015/16 to just under £800m in 2016/17. The Nuffield Trust calculates that the underlying deficit is £3.7bn. It also shows that a hospital will be given just £937 in cash during 2017/18 to treat a patient they would have received £1,000 to care for in 2009/10. Adjusted for inflation, the 2017/18 figure is closer to £760. Delaying planned operations will merely accentuate these financial problems.
Hospitals and social services were also expected to work together to reduce delayed transfers of care, where a patient is medically fit for discharge but neither home care nor social care is in place. Continual cuts in social care funding had created a situation where social services could not cope with the number of elderly patients being discharged from hospital; there were months in 2016/17 when over 6% of NHS beds in England were occupied by patients medically fit to be discharged. The government allocated £2bn to social services to reduce this proportion to 3.5% by September 2017, freeing up about 3,000 beds. This was not to be: in October 2017, the latest month for which figures are available, it was still 5.5%. By November, bed occupancy rates across England were averaging over 95%. As beds were cleared for the Christmas period, occupancy fell to 84.2% on 24 December. This prompted the-then Minister of State for Health Philip Dunne on 8 January first to trumpet this as a great success, and then to claim that ‘I do not have the figures for the most recent days’. This was a barefaced lie as he had figures for the weekend of 31 December which showed that occupancy rates were back up to 93.5%; by the first week of January they stood at 95% with 17 hospitals having rates of 98%.
High levels of bed occupancy make it increasingly difficult to find beds for emergency patients. A chain of consequences follows: patients have to wait on trolleys in A&E for a bed to become available; staff have to care for them and are therefore not able to deal with other patients coming through the doors; wait times for treatment therefore go up; ambulances are unable to hand over their patients so that more and more patients have to lie in ambulances for greater lengths of time; there are fewer ambulances responding to emergency calls and response times therefore go up. All along, the potential for harm to patients increases:
• A&E consultants from 68 hospitals wrote a letter to Prime Minister May saying that patients were potentially dying prematurely in corridors. One spoke of 120 patients a day waiting in corridors for a bed to become available. Elsewhere 50 patients were queuing for treatment in A&E. The appalling Philip Dunne dismissed this by stating that there were plenty of seats in A&E departments for waiting patients to use. At the time he made the comment, patients were having to sit on the floor in his local A&E department in Ludlow.
• The percentage of patients being treated within four hours at hospital-based A&E units in England fell in December 2017 to its lowest-ever recorded level – 77.3%. Only three of the NHS’s 137 acute trusts hit the national 95% target, while 32 were at or below 70%.
• Between 21 November and 14 January, 104,987 patients were held in the back of ambulances for more than half an hour because A&E departments were too busy to accept them. Of these, 24,624 had to endure waits of more than an hour. The proportion of such waits rose from one in ten at the end of November to one in six in late December.
• Over the same period, emergency departments were so busy that they had to divert ambulances to other A&Es a total of 188 times.
• An East of England Ambulance Trust review has uncovered 40 cases where patients ‘were harmed or died following significant ambulance delays’ in the three weeks from mid-December 2017.
• In a demonstration of the severity of the pressures, the entire Greater Nottingham health economy – hospitals, community, social and GP services – declared a ‘business continuity incident’ on 17 January because it was unable to cope.
• Staff shortages have been such that unqualified medical students from Keele and Liverpool university medical schools have been called on to volunteer their services, with the Keele head saying Kitchener-like ‘We are sure you will want to be part of our collective effort at this time of national crisis.’ However, the legal position should any of them make a mistake was quite unclear.
On 2 January, 55,000 patients waiting for operations had their treatment delayed until February. The government applauded this as a demonstration of sound planning. Apart from the inconvenience and worry it causes those affected and their families, the move will merely add to waiting lists which continue to climb inexorably, standing now at four million. A rise in the number of flu cases requiring hospital admission worsened the pressure on the NHS. Most involved a B-strain – so-called Japanese flu – rather than the expected A-strain from Australia. This was not covered by the trivalent vaccine that was used by the majority of GPs in the autumn inoculation campaign because it was cheaper than the quadrivalent version which would have covered the B-strain (£5 versus £8 a shot).
The annual winter crisis of the NHS is the most acute manifestation of a system which is being driven into the ground. The years of under-funding have left it shorn of adequate capacity. Britain ranks 30th out of 34 OECD countries for the number of beds per head of population, with 2.6 per 1,000 population. Most local Sustainability and Transformation Plans intend to cut the numbers further. Britain also ranks 24th of the 34 in terms of the number of doctors per head of population. More nurses are now leaving the NHS than are joining it: 33,500 left in 2016/17 while 30,500 joined. There are fewer district nurses and mental health nurses than there were in 2010. Health Care Assistants are being used regularly in place of mental health nurses in mental health hospitals. GP numbers are falling, and the GP journal Pulse reveals that GPs in Britain have an average of 41.5 patient contacts every day – 60% more than the 25 considered safe by European GPs. The government has no intention of restoring lost capacity: quite the opposite as its funding plans for the next three years show. The only way that we are going to change this is through massive class struggle on a scale to which the official trade union movement is completely opposed. Anything short of that will be completely inadequate.
Fight Racism! Fight Imperialism! 262 February/March 2018
