The latest, shocking statistics show the scale of the decline of NHS performance on almost all of its key targets: but the NHS was floundering BEFORE Covid-19 struck last year.
It needs more staff and more funding to run services, and capital to tackle backlog maintenance and refurbish and re-plan buildings to reopen beds closed during the peak of the pandemic. But questions must also be asked about the senior management of NHS England and its soon to depart chief executive Sir Simon Stevens.
Stevens’ announcement he is to stand down in July has triggered a sharply divided response, ranging from the brickbats of those who believe him to be the evil genius plotting to privatise the NHS, to veneration from fans who see only positives in his record, including crediting him with delivering extra cash, the Covid vaccination programme, and beginning to roll back Andrew Lansley’s disastrous 2012 Health and Social Care Act.
But if his fans give him credit for what has worked well, Stevens and the team around him must also share the blame for the decline in performance of NHS services since he took the top job in 2014. Had Stevens, a former Labour councillor and advisor to Tony Blair’s government, performed on a similar level as manager of a Premier League football team or many private businesses he would have been out on his ear several years ago.
He took over at NHS England after working nine years as a vice president of US health insurance giant United Health. Six months later he published a major policy document, the Five Year Forward View (FYFV).
Looking back at the 44-page FYFV is like stepping into a museum: most of the key commitments have long ago been sidelined or reduced to token gestures, not least the insistence that:
“The future health of millions of children, the sustainability of the NHS, and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health.”
In fact as the Covid crisis has brutally exposed, since 2014 we have seen year after year of cuts to public health budgets which are supposed to fund schemes to help tackle obesity and reduce consumption of alcohol, drugs, and tobacco. This is not Stevens’ fault: but what is his fault is that his plan rested on such unrealistic assumptions.
Many of the main FYFV ideas, whether people agreed with them or not, have also remained little more than words. For instance patients were to be given control over shared budgets for health and social care – a controversial idea with many campaigners. It also lacks sound evidence that it can work in the NHS. Stevens in a July speech in 2014 suggested “north of 5 million” such personal budgets might be operational by 2018, sharing £5 billion between them.
But this would have meant average payments of just £1,000 per year, £20 per week – well short of the amount required to secure any meaningful care package for any but the most minor health needs. In fact the latest figures show fewer than 89,000 people were receiving personal health budgets at the end of 2019 – a long way short of 5 million.
Carers, too, were promised new support by the FYFV: but the plight of carers remains desperate, with increased misery for many of them hit by the succession of welfare cuts and the nightmare of universal credit – with never a word raised on their behalf by NHS England.
According to the FYFV, barriers between GPs and hospitals, physical and mental health and health and social care were going to be broken down, with a shift of investment from secondary care into primary care. A “Forward View” for GPs was indeed published: but there it stopped. The under-funding continues, and the barriers are still intact. Overworked, under-staffed GPs face ever-increasing demands, with no sign of the promised increase in numbers or resources.
The FYFV also made bold promises to invest in more staff and improved services for mental health. Predictably none of these things have happened. Instead there are still thousands fewer mental health nursing staff now than there were in 2010, and the performance on almost every measure is as bad or worse than 2014.
After such a comprehensive failure to deliver almost any significant element of the FYFV, and the equal failure in 2016 to develop credible Sustainability and Transformation Plans, the likelihood of making the 10-year Long Term Plan (LTP), published in January 2019, any more than a wish list or a pious declaration was vanishingly small.
The Long Term Plan did contain a few positive concessions to the pressure of campaigners and the needs of patients:
- • New waiting time targets are to be introduced for adult and child mental health – although these are far from ambitious and without extra funding imply cutbacks elsewhere;
- • A promise of action to address unexplained mortality for people with learning disability and autism and the long waits they experience;
- • No explicit call to close acute hospital beds;
- • The idea is floated that the NHS take back responsibility for some public health provision.
These few positive elements must not distract us from the hard proposals in the LTP for a further top-down reorganisation of England’s NHS – into a centralised structure of 42 “Integrated Care Systems” (ICSs) within two years.
The Plan, now supplemented by the recent government White Paper required a series of mergers to reduce from 191 Clinical Commissioning Groups to just 42 ICSs from next April.
Tucked away in the LTP are more hard-edged proposals for increased use of private hospitals to deliver NHS funded care to limit waiting times. That was already being surreptitiously driven through by NHS England before receiving a massive boost during the Covid pandemic from the billions spent block-booking private hospital beds – and now the £10bn framework agreement for private hospitals to treat NHS elective patients over the next four years).
The LTP also put pressure on trusts to increase their links with the private sector to “grow their external (non-NHS) income” and “work towards securing the benchmarked potential for commercial income growth.” We can see evidence of this in new plans by major trusts such as Oxford University Hospitals and the Royal Marsden to prioritise expanding their private patient income even while NHS waiting lists are growing.
There also is an implicit threat of privatisation in the LTP proposals for new pathology networks and imaging networks to be established, in the absence of the necessary NHS capital for investment.
To sugar the pill, the Long Term Plan has to say something and so it rattles out upwards of 60 uncosted commitments to improve, expand or establish new services. Most of them, if taken at face value would be most welcome – but taken together in this context they are completely unaffordable, unrealistic and incapable of implementation.
There is promise after promise, many of them sounding great: prompt response services, proactive care, flexible teams, neighbourhood teams, primary and community care teams, community multidisciplinary teams and upgraded support. All these are presented in happy-clappy, completely abstract terms, without explaining how they were chosen, who would be responsible, or the timescale for implementation.
The Long Term Plan is a medium term threat to the services we all depend upon – and our ability to find out what’s happening and fight back locally to defend the services we need. With financial constraints limiting any real improvement, and a new system being imposed from top down and accountable only upwards to NHS England, patients and the public will have less voice and influence than ever in the shape of services and their access to them.
But if Simon Stevens has, as some believe, been an agent for US health corporations as part of a conspiracy aiming to “Americanise” the NHS, there is little sign the conspiracy is succeeding.
Centene is the only US health corporation to have made any substantial attempt to win contracts to deliver health care, buying up a network of profitable GP practices, but stopping short of bidding for hospital services. No other US health insurers have made any serious effort to set up in the UK, although some are keen to market their digital expertise, seeking lucrative but relatively small scale back office roles in the NHS.
In the US the data-driven techniques of “Accountable Care Organisations,” like similar experiments in England, lack evidence that behind the hype they can limit demand for care, deliver any significant benefit to patients, or save any significant money.
It’s worth noting Stevens is heading off to the House of Lords before these same methods are tried out in earnest (and at far greater expense) in Integrated Care Systems from next April. That means he can play a role in pushing through the coming Bill to give them legal status, but will not be around to take the blame when they fail to deliver any of the claimed benefits.
Stevens’ record in charge has been one of consistent failure masked by the rhetoric of grand, impractical plans, few of which have been more than partially carried through. He has proved to be neither the villain some feared nor the saviour of the NHS others hoped.
Praised to the skies by the Health Service Journal for ‘saving the NHS’ on three occasions, and as “the greatest strategic health policy thinker of his generation,” it’s true that Stevens cannot be held to blame for all of the failings of the NHS that stem from under-funding and government policy.
But the fact is that he leaves an NHS weaker than it was when he took over, with far greater dependence and higher spending on private providers. He also leaves a vacuum of leadership which could yet be filled by another Tory stooge or crony bad enough to make us regret his departure.
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