The NHS faces meltdown. The third week in November revealed the extent of the crisis: a 5% rise in attendances at A&E departments across the country compared to the same period in 2013 led to units as far apart as Cambridgeshire, Scunthorpe, Middlesbrough, Wigan, the Wirral and King’s Lynn urging patients to stay away. The situation has been made worse by cuts in social services which have meant patients cannot be discharged safely, reducing the number of available beds. The reason is quite simple: there is not enough money. Five years of flat-line funding has left it facing a £30bn budgetary shortfall by 2020. With their commitment to austerity, none of the parliamentary parties have the slightest intention of plugging the gap. In the meantime, stories of bad care and deteriorating quality are cynically used by the media to claim that a nationalised service cannot work.
The situation is deteriorating. At the end of the 2012/13 financial year, 45 NHS Trusts were in the red; a year later the total was 66. The number of Foundation Trusts in deficit doubled from 21 to 41 at the end of 2013/14 (out of 147). The King’s Fund at the end of October reported that one in three trusts was predicting a deficit at the end of 2014/15, including 86 Foundation Trusts, nearly 60% of the total. 10% of Clinical Commissioning Groups (CCGs) are also predicting a deficit. Overall, the NHS is on course to end 2014-15 almost £1bn in the red.
A report by the Nuffield Trust published in October 2014 revealed the consequences:
- The number of patients who had to wait more than four hours between a decision to admit from A&E and actually getting a bed on a ward (so-called trolley waits) rose from 93,905 in 2010/11 to 167,941 in 2013/14.
- On average, waiting times for elective surgery have increased by four days, and one in ten patients is waiting longer than the 18-week target.
- The number of nurses working in psychiatric hospitals has fallen by 13% since 2010. Waiting times for assessment have risen by a third over the same period. In November, the Royal College of Nursing reported that the number of mental health beds had fallen by 6% since 2010 while demand rose by 30%.
The number of people waiting for hospital treatment has gone over three million people for the first time since 2008. Without extra money next financial year, hospitals will be cutting staff, waiting times will get longer and care will become even poorer.
The market
The first step towards privatisation was the introduction of the internal market in 1991, with the split between purchasers and providers of care. 1992 saw the first Private Finance Initiative (PFI) projects; the 1997 Labour government adopted it in earnest to allow banks, service and construction monopolies to make huge sums of money from the NHS. £11bn of PFI investment will reap repayments of over £79bn; PFI repayments in 2012/13 were £1.76bn and will rise to £2.71bn in 2029/30. Money intended for public services is going straight into banks and investors’ pockets. Most hospitals with A&E departments threatened with closure are near another hospital with a large PFI debt: repaying that debt is the key priority rather than maintaining decent services.
In 2003, Labour decreed that all hospitals must become Foundation Trusts, every hospital an independent entity, a bedrock of privatisation. These Foundations Trusts are accountable to Monitor, the government-appointed competition regulator. Foundation Trusts can raise funds on the market and up to 49% of their income can come from private patients. However, it is in community, diagnostic and elective surgery services that money is to be made. Private companies have won 131 contracts for these services since April 2013 worth £2.6bn, about 50% of all contracts let in this period by value. With a total of £18.3bn of services up for grabs at the moment, private companies are on course to win £9bn worth.
Waiting times, cuts and rationing
In 2004, Labour brought in the four-hour waiting time target in A&E (from arrival time to decision time for treatment, discharge or admission), initially set at 90%, then up to 98% and reduced in 2010 to 95%. No good evidence links the four-hour target with reduced mortality or increased quality of care and few hospitals can consistently attain it. In 2005, the British Medical Journal listed reasons why the target is missed, including insufficient hospital beds available, delay in accessing specialist opinion and diagnostic services, insufficient nurses and doctors. Nine years on, the reasons remain the same.
In October this year, Monitor imposed conditions on the Heart of England NHS Foundation Trust, which provides services to over one million people across the West Midlands at four hospitals with 1,200 beds, in part because of its failure to reduce long waiting times in A&E. Monitor decreed that this demonstrated leadership failure and forced the resignation of the chief executive. Currently 14 Trusts have no chief executive, 21 have no finance director, 17 have no Chief Nurse and there are 16 top HR director and 14 Medical Director vacancies. In November, Colchester Hospital in southeast England declared a major incident after a Care Quality Commission inspection concluded that it was struggling with the A&E demand. The hospital reported 563 serious incidents over a two-year period. It is unable to recruit sufficient doctors or nurses because of its location and has to pay huge sums of money for agency staff to meet targets. In the last three months, the hospital has had three chief executives, three Chief Nurses, two HR directors, three finance directors and four company secretaries. It is now looking for its second Medical Director.
To meet financial targets, Addenbrookes hospital in Cambridge has decided to replace only one of two older CT scanners and is using longer-lasting gases to anaesthetise patients because they are cheaper. It has a significant shortage of experienced nurses in cancer, neurosurgery and intensive care departments and spends millions on agency nurses to fill the gap – up from £1.24m in 2013/14 to a projected £1.82m this financial year. In England generally, employment agencies charge £2,500 to £5,000 each time they find a new permanent nurse for a hospital. Addenbrookes has had to recruit 70 nurses from the Philippines this September; across Britain, nurse training places have been cut from 20,829 in 2010 to 17,219 in 2013 – for which there were 226,000 applicants.
In 2012, the ConDem government set up the CCGs, putting £88bn of the annual NHS budget in their hands. CCGs are headed by GPs and hold 80% of the annual NHS budget. Because of the cuts, GPs are now becoming rationers of care and are responsible for the dismantling of hospital services. New Devon is the largest of the 211 CCGs and is trying to recover money as it has a £14.5m deficit. It has therefore announced as a cost saving mechanism that it will deny routine operations to people who are obese or smokers. This includes hip and knee surgery which clearly would be hugely beneficial to those who are overweight to be able to exercise. The CCG is also bringing in criteria for hernia and cataract treatment and plans to reduce referral to consultant clinics.
None of the major parliamentary parties are proposing to address this crisis because of their commitment to austerity and the interests of the City of London. The Tories will continue their ruthless flat-line funding regime with an extra £2bn for 2015/16, the LibDems promise £1bn a year on top of this, but only from 2016. Labour, which has been as guilty as the Tories of introducing privatisation into the NHS, promises an extra £2.5bn a year but is unclear when it will be available. This will not fill the £30bn gap, and is a long way short of the NHS inflation rate of about 4%. There is no solution to the NHS crisis without struggle: it is up to working class people to fight every attempt to close or reduce services and to campaign against every act of privatisation.
Hannah Caller
Fight Racism! Fight Imperialism! 242 December 2014/January 2015
