With the Tory victory in the June general election, the process of wearing down the NHS continues apace. An election promise of an extra £8bn means nothing: none of it is available for the current financial year when, with demand overall increasing at 4% per annum, the actual increase in funding is a mere 1.3%, or in 2018/19, when it will be even less, 0.4%. The consequences are clear: longer waiting lists for operations, longer wait times for consultations, reductions in services, ever-extending eligibility criteria for receiving health care. 14 out of 44 Sustainability and Transformation Programme (STP) regions have been told to ‘think the unthinkable’ to meet the demands of a ‘capped expenditure process’: rationing will become the norm. Matters are only going to get worse as the number of nurses in training falls and half the current cohort of nurses become eligible for retirement by 2020.
Much was made of a report by the US-based Commonwealth Fund which rated the NHS as the best health system in a comparison with those of ten other advanced capitalist countries. Health Secretary Jeremy Hunt said ‘These outstanding results are a testament to the dedication of NHS staff, who despite pressure on the front line, are delivering safer, more compassionate care than ever.’ Yet the measures on which the NHS performed best were those that the ruling class are particularly interested in – affordability, efficiency and safety. When it came to outcomes – general public health, mortality which could be avoided by proper health care, and heart disease and cancer survival rates, the NHS was second-worst behind the US. This was despite the considerable improvements for instance in cancer survival rates in the first 15 years of the 21st century following a significant increase in the level of real funding. The cumulative effect of the years of cuts in NHS spending under austerity will inevitably send this into reverse.
The NHS is now going through yet another re-organisation following the disastrous consequences of the 2013 Health and Social Care Act. STPs have now become the cornerstone of the NHS. The 220-odd Clinical Commissioning Groups (CCGs) established just four years ago are now merging together within STP regions. The internal market, epitomised by the split between purchaser and provider, is withering away as the pressure is on to move beyond STPs to integrated Accountable Care Systems (ACSs) in order to promote further efficiency. The ruling class regards the NHS as an intolerable drain on its profits, and considers that choking off its finances is more useful than an uncontrolled expansion of health care privatisation. This would be inimical to the development of ACSs, and such privatisation as will continue will mainly be in support services. Hence a £5.9bn tender for community and some social care services within Greater Manchester STP was organised so as to effectively exclude all but a consortium of local NHS organisations from expressing interest. Rogue CCGs organising tenders for clinical services without reference to overall STP requirements will henceforth be brought into line. In the meantime, nine areas have been named as the first ACSs where ‘commissioners and providers come together to take joint responsibility for the health of a defined local population and the resources to deliver care services’ (Health Service Journal). This takes place under the aegis of the Next Steps of the NHS Five Year Forward View; the ACSs include Greater Manchester.
Developing STPs, let alone ACSs, will take years, however: STPs require a fundamental structural re-organisation as, apart from delivering local health services, they will also take over responsibility for social care. Furthermore, their financial viability depends on closing many local A&E services and centralising other hospital services which will spark inevitable local opposition. However, they also have to deliver enormous savings over the next two years. This cannot be achieved through any service rationalisation, but by cuts pure and simple. Fourteen areas, most of them STPs, have been instructed to ‘think the unthinkable’ and forced into the Capped Expenditure Process (CEP) to save an extra £500m a year. Most of them have been selected because they were deemed unlikely to meet their expenditure control totals. They include three London STPs, Staffordshire, and Sussex & East Surrey, and are required in euphemistic management-speak to make ‘difficult decisions’. These will include: closing wards and theatres; closing or downgrading other services; blocking choice of private providers for operations to keep money within the NHS; systematically extending waiting times particularly in services with lower-than-average wait times; stopping some treatments and stopping prescriptions for some items. In Surrey and Sussex, which is required to save a further £55m on top of £106m, ‘difficult decisions’ include the possibility of denying patients an angiogram or angioplasty.
In early July, NHS England chief executive Sir Simon Stevens said that only half the required £500m saving had been identified and that the search for the remainder had mostly stopped but ‘it’s time to be getting on with delivering’. Heads will roll if these 14 areas do not meet their target: what is much more important, however, is to what extent management will simply suspend essential services towards the end of the financial year to meet their CEP requirement. In the meantime, CCGs have been told to implement average efficiency savings of 3.8% this year; in 2016-17, CCGs had to plan for savings of 3.2% but only achieved 2.6%.
In the longer term, however, it will not be possible to deliver adequate NHS services because the staff will not be there – unless, of course, there is a massive influx of skilled migrant labour. The number of nurses on the register fell last year. This is not surprising: on average, nurses’ wages have already fallen 6% since 2010, and will have fallen 12% by 2020 because of a nine-year 1% pay cap. There are currently 24,000 nursing vacancies, and worse, half the current NHS nurse workforce of 315,000 will be eligible for retirement over the next three years. They are not being replaced: the consequence of abolishing NHS nursing bursaries and replacing them with student loans has been a dramatic drop in the number of nurse trainees. Overall, there are 19% fewer people this year applying for nursing courses; this includes all UK and EU applicants, with numbers down from 65,620 in 2016 to 53,010 in 2017. This is on top of the 96% drop in the number of qualified EU nurses applying to work in the NHS in the year since the Brexit referendum. The number of GPs in training is falling (see FRFI 256) so that the NHS will have to recruit 2,000 GPs from overseas; there is a need to more than double the number of A&E consultants over the next five years. The flagship Northumberland, Tyne and Wear mental health trust is raiding India for mental health consultants to meet the growth in demand especially from children and young people, up by 30-40% over the past four years.
Defending the NHS is a priority for any working class movement. There has been no significant resistance from the trade unions. The Labour Party manifesto promised an extra £35bn; this was already insufficient given the state of NHS finances. Labour will posture in opposition to STPs – but its manifesto only said that it would review them. The fact is that capitalism in crisis will not pay for a health service fit to meet the needs of the working class, and Labour in government will answer to the ruling class and to no one else. We need to create a new movement, one which will fight for a health service which is fit for the working class. Join us in that struggle.
Robert Clough
Fight Racism! Fight Imperialism! 259 August/September 2017
