Why is our NHS worth fighting for?
Good healthcare is a fundamental human right and must not depend on the ability to pay or individual insurance. Since 1948 our NHS has been publicly funded, publicly provided and free to all at the point of need. This is now being seriously threatened.
What’s happening locally in Waltham Forest?
The NHS is being starved of public investment across the country and Waltham Forest is among the areas hardest hit. Local health services have been told to make an 11% cut over the next five years, despite the borough facing significant levels of poverty and deprivation leading to ill health including very high levels of mental illness. Waltham Forest’s Clinical Commission Group (the budget holder) has the lowest funding per head to spend on health care in East London.
What’s happening at our local hospital, Whipps Cross?
Whipps Cross Hospital is run by Barts NHS Health Trust, which was formed in 2012 following the merger of three acute hospital Trusts – Barts and the London, Newham, and Whipps Cross. It is England’s largest hospital trust, consisting of five local hospitals serving East London and a population of around 2.5 million.
Barts also has the biggest Private Finance Initiative (PFI), used to build the new Royal London hospital in Whitechapel and redevelop the historic old St Bartholomews Hospital. Over the length of the PFI contract Barts will pay £7.1bn for construction and services for hospitals that cost £1.1bn to build. While the Trust is spending £2.5m a week on servicing its PFI debts, in 2014 it made £58m of cuts to the detriment of patient care. By March 2015 Barts was faced with the largest acute hospital trust deficit in the country, of over £93m.
Although not the sole consideration, the PFI debt was a significant driver towards the original merger leading to the creation of Barts NHS Health Trust. Spreading the PFI costs across the larger merged organisation was seen as a way of making the repayments less onerous.
The focus of Barts Health on cutting costs has had an impact on staffing, with the decision in 2013 to remove 220 posts across the Trust and down-band several hundred more nursing staff. A culture of bullying, harassment and low staff morale has also been reported. This in turn has had a significant impact on quality and safety of care.
By 2015, when the Care Quality Commission (CQC) issued its report of an investigation into the Trust, the findings were extremely critical. The report rated the care at Whipps Cross as ‘inadequate’, highlighting ‘significant concerns in safety, effectiveness, responsiveness and with the leadership’ and finding that ‘caring requires improvement’. The lead Care Quality Commission inspector stressed at the time that nursing and medical staff were not being blamed; rather, understaffing and poor management were the main factors causing the problems at Whipps Cross. By the end of March 2015, the whole Trust had been put on special measures, and many of the senior management of the Trust had resigned, including the Chief Executive and the Chair of the Board.
What about local GP Services?
Nationally GP services have been cut by about £1 billion and we’re 10,000 GPs short. In Waltham Forest 28% of GPs are over sixty. As they retire it will be even harder to get an appointment unless something is done to recruit locally.
What’s the situation with Community Services?
Waltham Forest’s community services, such as district nursing, children’s community nursing, health visiting and school nursing, are based in community clinics and provided by North East London Foundation Trust. Until recently all these services were commissioned by Waltham Forest Clinical Commissioning Group, but from October 2015 the responsibility for commissioning of children’s community health services has moved to the local council.
The council has put out to tender the contract for the provision of children’s community services, inviting bids from both private and NHS providers. The competing bids will be scrutinised and selected in spring 2016, with the first new contracts commencing in July 2016. Waltham Forest Save Our NHS believes that all of our health services should be directly provided by the NHS, so we have lobbied the council to choose an NHS trust and will campaign for children’s community services to remain with NHS providers. The track record, nationally, where private companies have taken over the provision of children’s community services, is not good; and we are very concerned about the safety of future services should they be transferred to a private provider.
What is happening to the NHS nationally?
What’s the situation with NHS funding?[i]
The Conservatives promised to ring-fence and protect the NHS budget. Spending in real terms on the NHS, adjusted for inflation, has remained broadly flat in the period since 2010. This is in contrast to the decade leading up to 2010, during which the real terms annual increase in spending was about 6.4%. Yet while spending levels have become static, demand for health care has gone up, not least because of cuts in social care as well as the increasing needs of an aging population.
Meanwhile, the NHS the administration costs have risen significantly, from an estimated 6% to 15%. In addition, many hospitals are burdened with high yearly payments for Private Finance Initiative (PFI) debts. This means less of the ‘protected’ budget is available to be spent on front-line care.
Many areas of health services, in particular GPs and district nurses and mental health services, are experiencing actual cuts. Since 2010 the NHS has also had to find huge efficiency savings worth £20bn, which have already resulted in cuts in staffing and services. Despite Cameron’s promise that he would cut the deficit and not the NHS, by October 2014, 66 maternity and A&E units had been closed or downgraded and 8,649 beds had been lost.
But, isn’t the NHS just too expensive?[ii]
We’re continually told that Britain can’t afford the NHS, but this not true. We spend the least on healthcare of most of the richest countries, including Germany, France and the US. And historically, with less money, we have offered better care. A 2010 report of the Commonwealth Fund, which surveyed 20,000 patients in 11 developed countries, found that the NHS was one of the most cost-effective health systems, with excellent access to care. Only New Zealand was cheaper and only Switzerland, spending 35% more, gave better access. In 2014 when the Commonwealth Fund reported again the UK came top based on quality of care, access, efficiency and equity. Bottom of the list was the US, which spends twice as much for worse outcomes and much worse access.
However, this is all under threat as the NHS is being starved of even the minimum level of funding required and as increasing privatization leads to more fragmentation, inefficiency and a deterioration of patient care.
What’s the problem with the Health and Social Care Act?[iii]
The 2012 Health and Social Care Act removed the government’s duty to provide a universal, comprehensive health service and opened all NHS services to competition, allowing private companies to make profits from NHS funding. Specifically, the Act
- involved a top down reorganisation of the NHS, at a cost to the public of £3bn, replacing the old bureaucracy with a new, more complicated one. In particular it led to the replacement of Primary Care Trusts with Clinical Commissioning Groups (CCGs), which have less responsibility to treat all patients in their areas;
- takes away the responsibility of the Secretary of State to provide comprehensive and universal healthcare provision, instead devolving responsibility to local decision makers. The Secretary of State now only has a duty to ‘promote’, rather than to ‘provide’ such a service;
- through the introduction of Section 75, requires all NHS contracts to be put out to competitive tender;
- lifted the cap on private income for NHS Trusts, so that they can earn up to half their income from patients who can afford to pay. In the current climate, where NHS funding has been frozen even though demand is rising, Foundation Trusts will be tempted to prioritise schemes by which they can increase their private patient income rather than those that benefit NHS patients directly.
Privatisation of NHS support services has been taking place within the NHS since the 1980s, including via PFI schemes (see below). In more recent years, some very limited clinical services began to be privately provided. But the 2012 Health & Social Care Act has paved the way for an acceleration of privatisation, with many clinical services contracts being awarded to private providers. This is largely happening through the decision made at local level by the ‘purchasers’ – i.e. the CCGs.
Won’t privatisation of health lead to greater efficiency and better standards of care?[iv]
There is no evidence that the price goes down and efficiency increases when private companies deliver NHS care. In fact, all the evidence points the other way. Costs increase and services may well get worse as the private sector typically cuts and/or downgrades staff and reduces the services on offer. Privatisation of hospital cleaning led to apparent short-term savings, but at the expense of lower hygiene standards, higher rates of hospital-acquired infection like MRSA, the break-up of established ward teams and underpaid and demoralised staff. In a similar vein, examples are now emerging of private companies that have taken over clinical services and made a real mess of things. For example,
- Circle Health was awarded a 10 year, £1 billion contract to run Hitchingbrooke Hospital in Cambridgeshire. Circle pulled out after three years, after telling its investors that it was “no longer sustainable” to manage the hospital, and following warnings from the Care Quality Commission about hygiene failures, staffing problems, poor care and the emotional abuse of staff.
- Serco has been heavily criticised for the poor standard of the service they have delivered and has now withdrawn from clinical services.
- Other recent failures have included a contract for cataract surgery that had to be terminated after a few days because of disastrous outcomes, and the discovery of unexplained deaths in private hospitals delivering care to NHS patients.
There are also fears that private healthcare providers will seek contracts for treating only those patients who create the most profit and the least risk for them (‘cherry picking’), leaving the NHS to cope with those patients deemed less profitable – such as those requiring more complex treatments.
According to a 2013 You Gov poll 84% of the public want the NHS to remain a not for profit public service, while only 7% favour privatisation. Eighty percent of people would be prepared to pay higher taxes for the NHS.
Where does the Private Finance Initiative come in?[v]
Hospitals built under the Private Finance Initiative where companies design, finance, build and operate services are an early example of privatization. The cost of PFI is a continuing burden for many hospitals. In 2013/14, 9 out of the 15 most indebted trusts had PFI schemes. PFI is now widely recognised as providing very poor value, costing nearly twice the amount of a publicly funded scheme. Around 100 NHS hospitals have been built this way, started by the Tories but implemented mainly under Labour. The cost to the taxpayer will be £80bn for hospitals that cost nearly £13bn to build.
What is TTIP and why is it relevant?[vi]
The European Commission is currently involved in negotiating TTIP, a free trade agreement of unprecedented scale between the US and the member states of the European Union, including the UK. It is not just – or even primarily – concerned with trade in goods, but also with trade in services. Its main aim is ‘liberalisation’ of the regulations governing trade and it will have a powerful influence on the kind of regulations that can be drawn up in future.
Many believe that public services in Europe, particularly the NHS, will be among the biggest prizes that TTIP will provide for US based corporations that are looking to expand. With the EU the site of nearly one third of world health spending, TTIP will create new markets for the private sector by opening up public services and government spending to unrestricted competition from wholly or partly US-owned, profit-driven corporations. The fear is that, if agreed, TTIP will change the whole emphasis of NHS health care: the priority will become the rights of transnational corporations rather than the care of patients. TTIP will even allow companies to sue governments if policy changes effect their profits, posing a direct threat to democratic decision-making.
What is happening to NHS staff?
When health services previously provided within the NHS are privatised, this has usually led to reduced pay and poorer conditions for staff employed by private companies in order to boost profits. Now changes are being made to the terms and conditions of NHS employees.
Firstly changes have been made to NHS, and other public sector pensions, meaning staff will have to work longer in order to pay in more for lower pensions. We are currently seeing attempts to reduce unsocial hours payments. We believe these changes are designed in part to make health services more attractive to private bidders. But, patient care depends on recruiting and keeping the right number of well trained and motivated staff who feel valued and we support NHS workers taking action to defend and improve pay and conditions.
Who runs what?
Clinical Commissioning Groups: The 150 primary care trusts that used to run local health services have been re-organised into 211 Clinical Commissioning Groups (CCGs). CCGs now make the decisions about what services are provided by which organisations. They have to make tough decisions about priorities, which could include closures of services or changes of use of buildings.
Investigations by the British Medical Journal in 2013 and 2015 have revealed a very high rate of conflicts of interest on the part of GPs with seats on CCG boards. In their 2015 study they found that CCGs in England have awarded hundreds of contracts worth at least £2.4bn to organisations in which their board members have a financial interest. These findings follow a previous investigation by the BMJ in April 2013 that found that more than a third of GPs on the boards of CCGs had a conflict of interest resulting from directorships or shares held in private companies.[vii]
Commissioning Support Units: much of the CCGs’ work is outsourced to ‘commissioning support units’ (CSUs), which are staffed by non-NHS employees.
NHS England: NHS England monitors the CCGs and CSUs.
HealthWatch: HealthWatch are the latest bodies set up to represent patient interests. They help patients deal with complaints and have a role in shaping local services. HealthWatch covers both health and social care.
Local Authorities: since 2012 local authorities have had a larger role in the NHS. All local authorities with social care responsibilities have Health and Wellbeing Boards, which have strategic influence over commissioning decisions across health and social care. They involve both democratically elected representatives and patient representatives, and provide a forum for challenge and involvement. Council health Overview and Scrutiny Committees also have the power to scrutinise “substantial” changes to services and to ensure change is preceded by proper consultation.
[i] Figures from this section drawn from: Jackie Davis, John Lister and David Wrigley’s NHS for Sale: Myths, Lies and Deception, Merlin Press, 2015; and the NHS Support Federation www.nhscampaign.org/NHS-reforms/nhs-funding.html
[iii] From Keep Our NHS Public (KONP)’s ‘Introduction for Campaigners’ available on KONP website.
[vii] See NHS Support Federation www.nhsforsale.info/database/impact-database/conflict-of-interest/CLINICAL-COMMISSIONING-GROUPS-GPs.html