John Lister –
Boris Johnson’s five minute broadcast on leaving hospital, in which he enthused about the NHS as the “beating heart of this country” and named two overseas nurses who he believed had saved his life might prove to have been a pivotal moment.
It might yet turn out to be the moment where he and his right wing cabinet were persuaded to pull back from the process of running down the NHS, slamming the door shut on migrant workers who throughout the life of the NHS have been key to its survival, and opening opportunities for private companies and private hospitals to carve out slices of the NHS budget.
Of course this has not ended the pressure from the neoliberal right wing of the Tory party and far right, who are yearning for an end of the crisis to further “reform” the NHS by intensifying competition at a time when collaboration has been proven to be key to the crisis response.
But their chances of success are limited by the reinforcement of the NHS during the epidemic as by far the most popular as well as the most universal public service, with even Dominic Raab suddenly singing its praises. The entire coronavirus pandemic and resultant crisis facing every major country in the world has been a wake-up call for ministers, and they have already been pushed into decisions we could not have expected a few months ago.
The financial constraints that have effectively frozen NHS funding in real terms in 10 years of austerity have been lifted to fight the virus, Priti Patel’s vicious Immigration Bill has been shelved, and health ministers and NHS England have been forced to put their plans for restructuring of the NHS on the back burner – or conceivably discard previous ambitions altogether.
The operation of the widely-despised 2012 Health and Social Care Act has been effectively suspended. Matt Hancock has been ignoring the Act, speaking and acting as if he is in fact responsible for the NHS; NHS England has taken over control at local level from Clinical Commissioning Groups; and the complex system of “payment by results” and contracting that were part of Andrew Lansley’s plan for a competitive market in health care have also been halted during the crisis and replaced by an old-style system of block contracts.
One HSJ analyst has argued how much better the NHS could have coordinated its work if the 2012 Act had not axed Strategic Health Authorities, and even Newsnight reporters have recognised that the 2012 Act has proved itself to be an obstacle to proper planning and coordination of services.
NHS trusts’ financial savings targets have been paused as well, to allow management to focus on their primary role of delivering health care. One top NHS hospital boss told the Health Service Journal: “It’s completely unrealistic to think about how we can make workforce reductions and workforce savings [given the expected coronavirus demand]. … We have to be 100 per cent focussed on clinical need.”
£13.4 billion of loans run up in recent years by trusts struggling to contain their deficits have also been written off – although it turns out this has been done (and could have been done at any time) without costing the Treasury any money.
NHS England has paused implementation of its controversial Long Term Plan, and urged local health bosses to do the same: already at the beginning of the year new NHS England guidance had called for an end to any further acute bed closures, and for bed numbers to be maintained at the higher level of winter 2019-20 – meaning that various plans for cutbacks and “centralisation” of services will have to be rethought.
In other words a completely new regime is now operating in the NHS, which has expanded its capacity, reopening closed beds as well as setting up temporary “Nightingale” hospitals, while its place in public affections has been reinforced.
So the question that arises is now people have seen how much better and more sensibly the NHS runs without the impediments of the 2012 Act, and how much better it can cope with additional beds open, how many of these generally positive changes can now be reversed, to restore pre-Covid-19 “business as usual”?
So now the Act has effectively been suspended, who can make a sensible case for bringing it back into operation, rather than scrapping the already widely-ignored and unpopular legislation?
And how can ministers who have so repeatedly and on so many different platforms professed their affection and admiration of the NHS during the epidemic follow the ending of the lockdown with a new financial crackdown that would require colossal, draconian cuts in key services, or a trade deal that would result in further widespread privatisation – especially to grasping American corporations?
There are other dilemmas, too, for the Tories when the crisis period is finally passed.
The NHS has block-booked 8,000 beds in private hospitals (the vast majority of Britain’s small-scale private hospital network) – to allow NHS trusts to continue with some of their more pressing elective surgery while switching their own capacity towards Covid-19 patients and increased intensive care units.
Unlike some other countries, the private hospitals have not been requisitioned, but commissioned at an estimated £300 per bed per day: this gives a lifeline to a small private sector that is heavily dependent on NHS-trained staff, and on income from elective care for NHS-funded patients – treatment which is suspended for at least three months and probably longer.
While the private sector hospital bosses expect to be able to “bounce back” after Covid-19, there should be a discussion about whether any of their hospitals should be taken over permanently by the NHS. Not all the private hospitals are large enough or near enough to NHS hospitals to be of value, but should those that are be nationalised and integrated into the public system that delivers care to all?
The wider role of the private sector must also come under the spotlight in any reassessment.
The highly-publicised 3,600-bed Nightingale Hospital created in London’s Excel Centre opened in record time – but with cleaning, and other support services contracted out to private companies including ISS, the company that triggered strike action from angry GMB members at Lewisham who had not been paid their proper wages as the epidemic set in.
So while the rhetoric of NHS England in recent years has focused on “integration,” and Tory ministers have insisted we must all pull together, the same NHS England has decided that the support staff at the Nightingale should NOT be part of the NHS team, but part of the profit-seeking private sector.
Across the country cleaners, porters and other support staff face the hazards of working with Covid-19 patients, many with inadequate personal protective equipment. At least two porters have died. Yet many of these services are contracted out to cheapskate employers, offering terms and conditions inferior to in-house NHS staff – especially on sick pay, which can result in pressure on staff, including outsourced 111 call centre staff, to come in to work while sick, potentially spreading infection. .
Recent research, looking at NHS data for 130 hospital trusts from 2010 to 2014 found that an average of around 40% of hospital trusts had contracted out their cleaning services, suggesting these contracts alone were worth £500m per year. The Covid-19 crisis is reminding so many more people that “unskilled” and underpaid staff in all public services are doing vitally important work, so it is important to ensure that the end of the crisis marks the start of a fresh campaign to bring all of these outsourced services in-house.
Department of Health and Social Care figures show the amount spent by the NHS on private providers of clinical services rose each year from 2006, from just over £2 billion to almost £9 billion by 2016, and the private sector share of NHS spending increased from 2.8% to 7.7% over the same period. However this flat-lined in 2016/17, and declined to £8.7 billion (7.3%) in 2017/18.
Other analysis by David Rowland of the Centre for Health in the Public Interest argues that the real level of spending on private providers of clinical services is much higher, with around 18% of NHS spending going to private providers other than GPs and dentists. This means £13.5 billion was spent on private providers in 2013-14, rising to £18.4 billion in 2018-19, a 36% increase.
Where does this money go? The BMA in 2018 found that 44% of NHS private spending was on community health services, 25% on general and acute services and 11% on mental health – although some sectors of mental health are extensively contracted out to private hospitals.
Analysis by Laing & Buisson in 2018 estimated 30% of mental health hospital capacity is now in the private sector. Other reports reveal 44% of the £355m NHS spending on Child and Adolescent Mental Health care goes to private providers. The private sector domination is most complete in the provision of “locked rehabilitation wards”, in which a massive 97% of a £304m market in 2015 went to private companies.
NHS acute trusts have been driven to outsource elective care to private hospitals. IFS figures show up to a third of NHS elective knee replacements and 20% of hip replacements are carried out in private hospitals.
In Devon University Hospitals Plymouth Trust has an 18 month partnership deal that moves 75% of the trust’s elective orthopaedic work to Care UK’s neighbouring private hospital.
However it’s worth remembering that the overall scale of the private sector is still very small: according to the Independent Healthcare Providers Network just 6% of NHS elective admissions are now going to private hospitals. This leaves the NHS to deal with the other 94% – as well as 100% of the emergencies, complex and chronic care.
In the post-pandemic rethink, it’s important to shine the spotlight on the scale of spending on private providers, and make the case once again for these contracts to be terminated and brought back in-house, with staff re-integrated into the NHS team, on NHS pay grades, terms and conditions.
Will post-pandemic Boris Johnson and his right wing cabinet be open to this? You are urged not to hold your breath waiting – but to press opposition MPs and the unions to take up the issue. A properly integrated NHS must not be seen as only for pandemics – we need it all year round!
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