About 29 million people in Britain are living with one or more long-term health conditions. The number of working age people reporting multiple serious health conditions has risen by 735,000 in two years. Billions of pounds have been cut from public services and social security since 2010 and health statistics are worsening faster in poorer communities. Glasgow Centre for Population Health has found that an additional 335,000 deaths were caused by austerity in the five years up to the pandemic, more than in the last two and a half years of the pandemic itself. Services essential to health care have been cut. Spending on housing services and homelessness prevention declined by 50% between 2009 and 2019. As a consequence street homelessness doubled between 2013 and 2018. It is also estimated that living in cold or inadequately heated homes causes 10,000 deaths per year. Even before the pandemic, life expectancy rates had become static for the first time in 100 years. Now, in deprived areas, they have started to decline. The gap in Healthy Life Expectancy between the most and least deprived areas is nearly 20 years. HANNAH CALLER reports.
The state of the NHS in 2023
The year started with several hospital trusts declaring critical incidents, meaning they couldn’t provide safe care. This is in the context of 7.2 million people waiting for elective hospital treatment, three times the 2009 figure, in a queue that isn’t moving. No more than 8% of people referred by their GP to hospital should wait more than 18 weeks, but almost 40% (2.9 million people) are waiting longer. Over 400,000 are waiting more than 12 months for consultant-led elective care. This figure was 1,613 people in 2020. Only 61.3% of people with a new cancer diagnosis started treatment within two months; the target is 100%.
On 2 January, while health secretary Steve Barclay was tweeting that the weekly 5k parkrun was ‘reducing pressure on the NHS’, a 92-year-old woman was in the news, weeping as she asked her family to let her die after spending 33 hours on a trolley in a hospital corridor. Both the Royal College of Emergency Medicine president and its vice president have been very clear that 300-500 people are dying unavoidably every week from these delays. NHS data shows that for every 82 people who wait for more than six hours in A&E there is one associated death.
The average ambulance wait for heart attacks and strokes is now over an hour (target 18 minutes); one quarter of ambulance A&E handovers take over an hour due to full departments (target 15 minutes). In England, the A&E four-hour target is now met for only 69% of people (target 95%). In January 2023, for the first time, over 50,000 people per week waited more than 12 hours in A&E to be admitted for treatment, up from 10,000 a week in 2019.
A surge in cases of flu, higher than usual numbers of Group A Strep infections and rising Covid-19 cases have put additional pressure on NHS capacity. In mid-January, hospital bed occupancy was 93% in England and Wales, with 12,809 beds every day taken up by people declared medically fit to be discharged – a third higher than in 2022. 85% bed occupancy is considered the safe level.
The scourge of austerity
At the start of the pandemic in 2020, the NHS had fewer beds, staff and equipment per head of population than most comparable OECD countries. Over the last ten years, the number of admissions has risen by 21%, while the number of nurses working in hospitals increased by only 8%. Total staff vacancies in the NHS are over 105,000, with 47,000 nursing vacancies in England, 12% of nursing posts, and a shortage of 2,000 midwives. On 27 January it was reported that the government would fine universities if they exceeded the cap of 7,500 medical school places despite the shortage of doctors. Freedom of information requests to every English NHS trust showed they paid £3bn to agencies for staff during 2021-22, 20% more than in the previous year. In addition, trusts spent £6bn on so-called ‘bank staff’ – health care workers doing additional shifts, mostly in their own hospital, to fill rota gaps (The Guardian, 11 December 2022). At the end of 2022, Chancellor Jeremy Hunt announced a further £3.5bn for the NHS for 2023/24; this is just half a predicted shortfall of £7bn. At the same time the government is demanding impossible additional ‘efficiency’ savings of 2.2%.
Former Conservative health secretary Sajid Javid is now calling the NHS model unsustainable, saying people should be charged to see their GP and for any A&E attendance, and envisages radical reform to include ‘extending the contributory principle’ with means-tested fees to help deal with waiting lists. Prime Minister Rishi Sunak previously had plans to fine people if they missed hospital or GP appointments. The Tory right-wing is pushing to formalise a two-tier system (which in practice operates already): while far more expensive overall, it will allow the wealthy to jump queues and get preferential treatment.
Labour Party in opposition
If the Labour Party were any kind of opposition at all, it would step up to defend the NHS. After a near-collapse of the NHS in 2000 because of the Blair Labour government’s commitment to the previous Tory government’s spending plans, better economic times allowed it to increase NHS spending and by 2009, median waits for elective care were below five weeks, and over 90% of non-urgent cases started treatment in less than 18 weeks from referral. However, Labour’s Plan 2000 diverted much of the additional funding to privatised Independent Sector Treatment Centres, which drove up health inequalities without reducing waiting times. Current shadow health secretary Wes Streeting says that Labour’s plans to use the private sector to help reduce NHS waiting lists would be a short-term measure that is only being proposed because of the current situation. But there are only 8,000 private hospital beds across the country (compared to about 100,000 general and acute hospital beds) and they are dependent on NHS doctors creating time for private practice. They are not even a sticking plaster.
Labour leader Keir Starmer says the NHS must ‘reform or die’, while in an interview for the Sunday Telegraph, Streeting decided there was a ‘something for nothing’ culture in the NHS and claimed the doctors’ union, the BMA, was hostile ‘to the idea that with more staff must come better standards for patients’. In the midst of a global capitalist crisis, where nurses are having to use foodbanks set up by hospitals, and with life expectancy falling, he tells us ‘if the NHS is going to continue to look after us, then it has to change. And only the Labour Party has the permission to make that change. We founded the NHS. We understand it.’
Keir Starmer and Wes Streeting propose reforming what they call ‘bureaucratic nonsense’ so that people can self-refer to specialist services ‘to create more front doors in the NHS so that people get seen faster and reduce pressure on GPs’. It is nonsensical: self-referral on an unsustainable scale is already happening – it is called attending A&E. The example they use to illustrate their proposal – internal bleeding – can have many causes, some of which can be treated by a GP anyway, like stomach ulcers. But if the patient self-refers to the wrong consultant, what then? The cost of a GP appointment is £40, that of an outpatient appointment £250. Rather than address the immediate problems, like falling real pay, they want us to look elsewhere for solutions, hence their proposal for the direct employment of GPs (currently run as small businesses) – which won’t address the lack of GPs, down by 1,973 since 2015.
Pay and conditions
Since 2010, all clinical professions have had a major real-term fall in income. A recent Royal College of Nursing (RCN) survey concluded that 50% of nurses are thinking of leaving; a British Medical Association survey showed four in ten doctors in training would like to leave the NHS and two thirds have researched alternative careers, while senior doctors are retiring early. There have been 15 years of real-term pay cuts for doctors in training in England, resulting in a 26.1% decline in pay since 2008/09 and the RCN says experienced nurses are 20% worse off in real terms than a decade ago. Nurses are striking, alongside ambulance staff, and doctors in training will walk out for 72 hours in March. Starmer and Streeting have refused to support the RCN or the strikes: they do not want to lose the votes of the most reactionary sections of the electorate.
Social care
On 1 January 2023, 12,938 out of 18,612 people ready to be discharged from hospital in England could not be because of inadequate support arrangements. In Scotland, 1,700 people were medically fit for discharge. On 9 January, health secretary Steve Barclay announced £200m for the NHS to buy 3,000 beds in care homes, independent hospitals, hospices or hotels. How these are to be staffed has not been considered. Hospitals in southwest England have set up ‘care hotels’ to discharge people who can’t be transferred into social care. These are staffed by live-in care workers provided by private homecare companies. Devon opened a 40-bed care hotel, announcing that the CQC-registered care agency complies with all infection prevention and control measures.
There is no simple fix. One in nine social care posts is vacant and pay and conditions are poor. People deemed fit enough to be discharged into hotels need support and supervision, such as from physiotherapists, occupational therapists, elderly care doctors and district nurses. Those trying to get back home may end up stuck in another facility.
In 2022, Hunt announced an extra £7.5bn for social care over two years, but half of it will come from postponing the new £86,000 cap and other funding reforms, and a quarter will require councils to raise council tax. The cash injections to social care supporting discharge from hospital have never compensated for the cuts. The Health Foundation suggested that by 2030 adult social care in England would need an annual uplift of £8.9bn just to maintain the current level of service, and £14.4bn to restore access to historic levels. Social care access is already heavily rationed by strict eligibility thresholds and means testing.
Managed decline
The crisis in the NHS has been created by a sustained failure of investment for the last 13 years, flatline funding for the first five years and barely visible increases since. The NHS faces real-term funding cuts of £4-9bn, so the £500m promised to tackle delayed discharges this winter is too little too late. Over the past decade, British investment in health care capital as a share of GDP has been consistently lower than in comparable countries. Private Finance Initiatives have plunged whole trusts into debt. Healthcare spending per person in Britain is the second lowest among the G7 group of large economies. The OECD average of hospital beds per 1,000 head of population is 4.7; in the UK it is 2.5. The number of practising doctors per 1,000 head of population in England is 2.8; only Poland among OECD-member EU countries has fewer. The EU average is 3.7.
Dressing up the failure of investment as a problem of the model of healthcare, as both the Tories and the Labour Party are doing, is deception. In its drive to maintain profits, capitalism will stop at nothing; its current crisis is impoverishing millions of people. The Labour Party yet again is showing that it cannot solve the crisis in the NHS, because the solution lies in challenging the whole capitalist system. The poorer people are made, the sicker they become and the more they need healthcare.
Fight for the NHS! Fight capitalism!
FIGHT RACISM! FIGHT IMPERIALISM! 292 February/March 2023
