NHS crisis bites deeper

Workers taste the bitter fruit of capitalist market ‘reforms’.

Proletarian writers

A&E departments have become so overwhelmed that nurses have been treating patients stuck in the back of ambulances outside.

Proletarian writers

In January 2018, the Guardian published an article titled NHS: up to 100,000 had to wait 30 minutes in ambulance this winter.

It cited ‘latest figures” showing that “almost a quarter of those had to wait at least an hour before being seen. In all 104,987 patients brought to hospitals in England have been stuck inside an ambulance, or in parts of hospitals including corridors, for upwards of half an hour.

“They have faced long waits because A&E staff, struggling to cope with a surge in demand for care, have been too busy to accept them at the time they arrive …

“The eight weeks since then have also seen emergency departments forced to temporarily divert patients to another hospital a total of 188 times.” (Denis Campbell and Pamela Duncan, 18 January 2018)

Whence the crisis?

Anyone that has – like this article’s co-author – worked in a hospital A&E department in any capacity, or indeed in any hospital in the NHS, will know that closing down an A&E department to new admissions is not a decision that is lightly taken. Doctors, nurses and healthcare workers take their duties incredibly seriously and strive to provide the best possible care for all who come asking for help.

And yet 188 times this winter, A&E departments have shut their doors. We are led to believe that this is due to a ‘peak in demand’. And yet the population of Britain is largely static. The seasonal patterns of illness are not new – they are entirely predictable. So why does the entire health system now grind to a halt when Britons are touched by a bout of flu?

Is it simply that the British, formerly famed for their ‘stiff upper lips’, ‘calmness in a crisis’, and ‘empire-building spirit’ are utterly unable to predict, plan and manage? Certainly, if one looks at the way our transport system grinds to a halt if the ‘wrong kind of leaves’ fall on railway tracks, or a touch of light drizzle falls on the capital, one might be forgiven for thinking so.

But let us ask another question. What has changed to lead to this generalised acute healthcare ‘acopia’?

The NHS has not always proven unable to cope. From the service’s foundation, healthcare provision and health outcomes routinely improved, and Britons were proud to point to the NHS as an unalloyed success – even celebrating it in the opening ceremony of the 2012 Olympic Games, held in London. Although loosely modelled on the Soviet system of healthcare introduced decades earlier in the USSR, we championed it as a world pioneer, and it genuinely was the envy of many other nations.

‘Surge in demand’ or lack of capacity?

It is quite clear to all NHS workers that what has changed is the capacity of the NHS. Every hospital rebuild that has taken place over the past 20 years has gone through on the assumption that there is ‘overcapacity’, and PFI redevelopments in particular have been predicated on the principle that savings will be made by reducing bed numbers in the newly-built hospitals.

This was allegedly justified by modern procedures, modern care, laparoscopic and minimally invasive techniques, improved outpatient care etc. All of this has reduced average hospital stays, true enough. But in fact, the selling-off of cottage hospitals and rehabilitation facilities, along with the closures of services, wards and major hospitals, has now reduced bed numbers well below the actual population demand.

In addition, reduced social care budgets and facilities mean long waits for many who are no longer fit enough to return to their own homes after illness, and very often lead to lengthy disputes with patients who are subjected to the indignity of means tests while still in their sickbeds, and who are in many cases forced to sell off their meagre assets in order to pay for their own rehab and social care.

So when cold weather and flu tips the balance of many elderly and chronically unwell patients in the direction of needing in-patient care, and increased numbers pass through the doors of our A&E units, staff there may well be able to see, triage, and initiate treatment of all comers, but the receiving wards in our hospitals are simply bursting at the seams with patients who cannot be discharged.

There is simply not, any longer, the capacity and throughput to cope with the seasonal demand.

Britain has one of the lowest rates of hospital bed availability per head of the population in Europe and the developed world, at less than 2 per 100,000. And this is before the next wave of hospital closures hits as part of the threatened (and laughably named) ‘Sustainability and Transformation Plans – which we will mention below.

It is this same reason that leads to incredibly high rates of hospital bed occupancy (98-99 percent) across the NHS, and in turn is a factor that tends to increase the rate of hospital acquired infection.

The NHS remains our most loved institution – what is causing the crisis?

The National Health Service, beset as it is by consciously engineered problems of perennial funding shortfall, remains the most cherished institution of the working class. British workers overwhelmingly want to defend the NHS, as local hospitals and services are subjected to ongoing campaigns of closure.

But these threatened hospital and service closures are often masked by slick PR campaigns which imply that closures are simply ‘centralisations’ of services and expertise, and the aim of such cuts is clinically driven and to provide better care.

We have previously outlined the means by which consecutive governments – Labour, Tory and ConDem – have outflanked public opinion in order to force privatisation on the NHS.

Each measure adopted in the name of ‘defending and improving healthcare’ has been designed to tighten the financial screws and move towards a healthcare crisis which in turn can be used to sacrifice the NHS founding principle – of quality healthcare available to all, free at the point of delivery, from the cradle to the grave – on the high alter of mammon, for the benefit of the fabulous profits of the free-market fundamentalists, who care nothing for the plight ordinary workers will suffer.

They can be summed up briefly as follows.

– Introduction of the internal market, which wastes approximately 15-20 percent of the NHS budget on needless accounting and management. We are effectively buying from and selling services to ourselves, and using an army of overpaid city accountants and auditors to oversee the ‘efficiency’ this absurd process.

– Relative underfunding of healthcare, generating a desire for private services in those who can afford it, in order to queue-jump.

– Leaving key healthcare sectors in private hands, letting ‘profitable’ procedures and services fall into the private sector while keeping loss-making treatment public.

– Labour’s flagship Private Finance Initiative, or PFI, in which NHS funds are used for huge interest payments to consortia of capitalists, instead of being used to build and run health facilities for workers. The PFI, responsible for £80bn of debt, if cancelled, would alone redress the current NHS budgetary crisis.

– Reduction in hospital beds, services and facilities; combining health and social care budgets, but with overall reduced funding and increasing use of means testing.

– Concentration of budgets in the hands of GP consortia (Clinical Commissioning Groups or CCGs), who by design are unable to plan health provision nationally – or even locally – and are ripe for corporate plunder.

– Planned merging of CCGs with big health insurance interests (United Health, the US titan for which NHS England chief executive Simon Stevens worked for a decade before being invited back through the ‘revolving door’ by the British government to deliver the coup de grace to our health service) to form ‘accountable care organisations’ (ACOs), or ‘health management organisations’ (HMOs), which is, in effect, the introduction of the failed US health model by stealth.

Simon Stevens and United Health – wolves dressed as shepherds

The last steps toward complete privatisation of our healthcare system and its transformation into an insurance model come with the abolition of the responsibility of the secretary of state for health for providing NHS care and the passing of the ‘NHS’ baton (increasingly less national; increasingly divided and privatised) to the electorally unaccountable chief executive Simon Stevens, has all been smuggled in within the pages of the 2011 Health and Social Care Act.

In case there are any doubts about the long-standing remit of the person running our NHS, he can speak for himself. In October 2013, Stevens’ speaker biography for a health networking conference read: “His responsibilities include leading UnitedHealth’s strategy for, and engagement with, national health reform, ensuring its businesses are positioned for changes in the market and regulatory environment.”

The latest buzzwords for these policies are designed by Stevens himself. ‘Structural transformation programmes’, now rebranded ‘sustainability’ and transformation plans, which are in effect simply massive budgetary cuts to the tune of £5bn in London alone, and the ‘five-year forward view’ – which devolves responsibility for the entire programme of social welfare spending onto local councillors.

Five-year plan for the NHS?

Considering how Tory backbenchers love to denounce the NHS as a ‘Stalinist organisation’ (and in this there is a grain of truth, if not the pro-market-fundamentalist one they are reaching for) in need of radical market ‘reform’ (in this ‘hair of the dog’ prescription, they are quite wrong), one may be forgiven for asking why Jeremy Hunt is suddenly so enamoured by the concept of a ‘five-year plan’ for the NHS?

The answer, unfortunately, is that the five-year forward view is not a plan for construction; it is a plan of destruction. Many of the threats to the NHS, and indeed of the actual attacks, have not been recognised as such over the years because bourgeois politicians and their parties of all hues have worked hard to mask the real nature of the slaughter of the NHS.

These bourgeois politicians criticise the ‘failings’ of the NHS, without ever addressing the cause, or seeking to lay out any policy that might actually be able to redress the malady and reverse the policy trend. Labour is equally culpable and as deeply complicit as the Tories in the attacks on the NHS, yet it continues to masquerade as the party that stands for the NHS.

It is a mixture of naivety on the part of British workers and Labour voters and misinformation from Labour and its various political hangers-on that allows the party to carry on with this charade.

The crisis that has hit our NHS this winter cannot be covered up and has been predicted for some time. Indeed, it is hardly surprising that it should occur when the service has been systematically bled dry of much-needed cash to fund maintenance of hospitals, services and staff.

We have seen in recent years escalating attacks on the payment, retention and training of healthcare workers. What all can now see is hospitals that are in urgent need of repair or that are being held to exorbitant ransoms by private companies under PFI schemes, a shocking lack of beds throughout Britain due to hospital and ward closures, and an equally shocking lack of all levels of medical staff (nursing posts alone make up most of the reported 45,000 unfilled clinical roles across the NHS).

There is an inflated and extremely costly level of management in these hospitals, whose members are allowed to indulge in all kinds of ‘get rich quick’ tricks such as retiring one month to get all their pensions and bonuses and then taking up the same post on the same salary a month later.

These ‘managers’ receive these outrageous rewards in return for services to privatisation such as cutting the numbers and wages of frontline staff to the bone. Cheaper, more ‘flexible’ (ie, overworked) staff with few or no rights and no real bargaining capacity are, after all, a primary precondition for turning hospitals into profitable businesses.

In order to give the impression that there are enough staff, the management create ‘unworkable systems’ that leave more and more patients in danger, as the doctors and nurses that we do have are savagely overworked and overstretched and finding that giving proper care to their patients is being made daily more impossible.

Add to this the huge and very hungry pharmaceutical giants with their vastly overpriced drugs that they are virtually able to force the NHS to buy, and it can be seen that unneeded and greedy managements, private firms operating PFI protection rackets, and the real drug cartels of big pharma are all shovelling huge sums of public money out of the NHS while putting little or nothing back in.

And before we think that this constitutes an ‘enough is enough’ situation, there is far more to lay bare. The rise of the Clinical Commissioning Groups, which were given the task of putting all health procedures out to tender, was another step towards the destruction of the NHS as we thought we knew it.

This has meant that, according to the department of health accounts, the private sector, hiding under the banner of the NHS, was given a total of £8.7bn worth of NHS services to deliver for 2015-16 – or about 7.6 percent of the total NHS budget. The figures given do not include the areas of general practice, dentistry and community pharmacy, within which a very large private sector lurks hidden by being allowed to use the NHS logo alongside their company logos.

Some may argue that surely if the service is being delivered it doesn’t matter who carries it out, but a private company exists to make a profit for its shareholders; that is the only reason for its existence. The best profits in health provision are made from relatively easy procedures, of course, any difficult illnesses or long and tricky operations that may only generate the same return as the quick and easy ones will be pushed to the back of the queue.

And it is hardly a heartening thought for a patient to think that, however routine their operation may be, it will probably be performed by the company that offered the lowest tender and may as a consequence be cutting all sorts of important corners to increase its profit margin.

Are these private companies really so strong inside the NHS some might ask? Despite the government’s pledge to reduce private firms’ involvement in the NHS and health secretary Jeremy Hunt’s repeated claims that such contracts merely account for a marginal part of health provision, last year private firms won 267, nearly 70 percent, of the 368 clinical contracts that were put up for grabs, worth £3.1bn according to a report from a campaign group that monitors the level of NHS privatisation, the NHS Support Federation.

Branson and Virgin – the nation’s largest GP

One of the biggest private healthcare providers leeching off the NHS is Richard Branson’s Virgin Care, with around 400 current NHS contracts to its name. The interest in the NHS by this parasite is plain. Despite earning around £200m over the last two years, with a clear profit of £15m, Virgin has paid no tax whatsoever, therefore put nothing back into the public purse that funds the NHS.

Richard Murphy, a chartered accountant at Tax Research UK, claims that Virgin Care has been able to avoid tax payments by making use of 13 holding companies, some of which are registered offshore, which act as a buffer between itself and its parent company Virgin Group Holdings, based in the British Virgin Islands and citing Richard Branson as sole shareholder.

The worth of NHS contracts held by Virgin has risen by 50 percent over the last year and includes a five-year contract with NHS and the local authority in Wiltshire worth £64m, a seven-year contract with NHS East Staffordshire Clinical Commissioning Group (CCG) worth £270m, and another seven-year contract with NHS Dartford, Gravesham and Swanley CCG, a seven-year deal to provide over 200 adult and children’s health and social care services in Bath and North East Somerset worth 700m, a five-year £65m contract to deliver urgent care and community health services for adults in West Lancashire and another contract with NHS Swale CCG, worth £126m.

Of course, with the tender system, not all those bidding can win, but there are still more ways to make a fast buck from this farcical process. When Virgin lost out on a lucrative three-year contract to provide children’s services in Surrey worth £82m it sued the NHS. The deal covered health visitors, school nurses and speech and occupational therapy for children, and it was won by a consortium formed by in-house NHS providers and a social enterprise.

Virgin claimed that “there may have been serious flaws in the procurement process”, and, stymied by new business-friendly laws, the NHS settled for an undisclosed amount that was rumoured to have left it with liabilities of hundreds of thousands of pounds.

Virgin Care is also believed to be a contender for either part or all of £1.2bn worth of contracts to provide cancer and end-of-life care in Staffordshire, which will be one of the biggest and most wide-ranging NHS outsourcing deals to date. Along with Virgin, the terminal illness care contract has two other bidders: Optum and the Interserve consortium. A winner or winners will be announced towards the end of 2018.

The ‘free’ market in healthcare – capitalism is the disease, not the cure

It should be clear to all by now that capitalism has no place in healthcare provision. Indeed, we are of the ardent belief that it serves no useful purpose anywhere anymore, but as the crisis becomes so obvious it is almost amusing to watch the various bourgeois politicians (paid lackeys of imperialism that they are) trying to gain the trust of the working classes in Britain.

As NHS managers announce that a month’s worth of non-urgent operations and appointments are being postponed in order to cope with the crisis, we have the doubtful consolation of seeing the prime minister and her health secretary humbly apologising to the patients concerned and all the British people, while still trying to convince us that they care for the health service.

The new line being put forward by various politicians seems to be that the crisis is all the fault of short-term and partisan party politics, and if they (ie, the parliamentary parasites) could all just all work together, they could get it sorted out. But since the main parties have all followed exactly the same agenda separately, we cannot for the life of us see how working together will bring about a change in the result!

The only difference is likely to be a reduction in public division and argumentation, which does occasionally reveal to workers the odd dirty truth that lies behind the smooth and distracting narratives collectively presented by Westminster spivs, privatisation managers and the presstitute fraternity.

Nick Timothy, formerly Downing Street joint chief of staff under Theresa May and still said to be a confidant and advisor to the PM, has said that the health system was ‘unsustainable’ without structural reform and more money in an article he wrote for the Daily Mail. He has also stated, along with Sarah Wollaston, the Conservative chairwoman of the health select committee, that there is a case for getting workers over the age of 40 to pay more income tax, and for wealthier pensioners to pay more in contributions so that the burden on younger workers might be reduced.

So, if the ideal NHS is expressed as ‘publicly owned and free at the point of use’, this latest proposal leaves us with ‘privately owned and increasingly costly the longer you live’: ie, expensive at the moment where most use is probable!

Many campaigns that have sprung up to defend the NHS, while welcome, have a tendency to be too narrow in scope and to allow themselves to be misled by politicians’ promises. Only by clearly understanding our rulers’ determination to dismantle the NHS and by coordinating our efforts to save it can we hope to succeed.

We must demand:

1. The immediate scrapping of all PFI debt.

2. The scrapping of the ‘internal market’, which pushes privatisation, not ‘efficiency’.

3. The scrapping of the STPs and their associated cuts.

4. The scrapping of foundation trusts, CCGs etc, which act as businesses first and health providers second.

5. The reintroduction of integrated health planning, commissioning and provision on a national and regional level by the NHS.

6. An end to the private provision of healthcare, which doesn’t ‘add choice’ or ‘increase overall health funding’ but only adds cost, and ultimately deprives the poor of healthcare.

7. An end to pay freezes and ‘restraint’ for NHS workers, and the restoration of national employment contracts and frameworks.

8. The nationalisation of all drug and medical technology companies. It has long been the case that while public debt is social, profitable enterprises are in private hands.

The CPGB-ML believes that the welfare of workers can only be safeguarded by a socialist system of economy, controlled and administered by the working people themselves. Let the capitalists’ ministers try and show us otherwise; let them start by meeting this list of simple demands.