John Lister is director of Health Emergency and editor of Health Campaigns Together newspaper, www.healthcampaignstogether.com He writes here in a personal capacity.
The tens of thousands who will protest in London on March 4 against cuts, closures and privatisation of the NHS in England and against brutal cuts in social care will make it the biggest demonstration on the NHS in decades.
But with Theresa May and her ministers keeping their heads firmly in the sand and ignoring the obvious signs of growing crisis across the country, and clearly not at present feeling threatened by the parliamentary opposition, it’s already clear it will take a lot more than a big protest to change their minds.
The trouble with trying to reflect public support for the NHS and opposition to attacks on it through demonstrations is that however big the protest, it never fully matches the numbers who back the cause but can’t join the action, or have not yet been persuaded it’s an urgent enough situation for them to get involved.
Some of the biggest victims of the Tory attacks on health and social care simply cannot physically join in: among them are tens of thousands of frail older people trapped in hospital beds for lack of services to support them, some of them forced to sell their homes and liquidate their hard-earned savings to pay the full cost of poor care in miserable quality care homes.
Many more older people are stuck in their own homes, struggling to survive with minimal help from cheap and nasty, poor quality domiciliary services delivered in inadequate 15 minute fleeting visits from demoralised care staff, super-exploited on minimum wage by grasping private companies.
Even more are among the hundreds of thousands of older people who have been squeezed out of eligibility to any care whatsoever because they are not severely enough in need.
This has come after years in which local authorities have responded to outright cuts each year in their funding from central government by raising the threshold for accessing care, so they can slash services to a bare statutory minimum. Add to that tens or hundreds of thousands of mainly women who have found themselves acting as the unpaid, unrecognised carers for older relatives and spouses who cannot get proper support.
Few people who have encountered it in real life believe that this is the way social care services should be delivered. It has all the worst hallmarks of cutbacks and privatisation.
The cutbacks have been brutal. Local government funding, which is key to paying for social care, will be just 28% of its 2010 level by 2020. And clever wheezes to cut money out of NHS funding to prop up social care just reallocate the deficits and fall far short of solving any of the real problems.
Very few if any of these people hit by these problems will be on the march: but many of them have good reason to understand what the Tory strategy of cash starvation is doing to social care and – more subtly – to the NHS.
The subtlety is because NHS spending is not being overtly cut in cash terms in the way council funding has been cut: ministers are not actually lying when they respond to criticism by claiming they are spending the largest-ever amount of money on the NHS.
The fact is that it’s not the size of the pile of cash that needs to be counted, so much as how much health care it will buy, and what volume of services – and even how many people – it needs to cover.
Serious analysis by the Nuffield Trust of the Tory claim of £10 billion extra for the NHS by 2020 shows that in real terms and after all the additional costs are taken into account the “£10 billion extra” is in fact extra spending of just £800 million – less than a tenth of the amount – across the whole of England, over five years.
Add to that the fact that a virtual freeze in real terms NHS spending was applied in George Osborne’s first budget back in 2010, after a decade of above-inflation growth under Labour, which aimed to increase the share of British GDP spent on health to nearer the European and OECD average.
That means the real terms value of the cash increases each year since 2010 has crept up by a pitiful 0.9% per year– while cost pressures on the NHS, from inflation in costs of drugs, equipment etc., new drugs and techniques and rising numbers of older people who on average are more costly to care for, increase by around 4% a year.
Add to that also the fact that the population has been growing and is now around 4 million higher than it was in 2010, and it’s clear that less money in real terms is being divided between more people: spending per head is actually going down between now and 2020.
We are in the middle of the meanest-ever decade in NHS spending growth, meaner even than Thatcher’s miserable 1980s. The Osborne cuts, still in place, aim to reverse the whole of Labour’s funding increase and roll back NHS funding as a share of GDP to what it was when Tony Blair took office. We are in severe danger of being dragged back to the 1980s, with all the horrors of cancer and heart patients dying on waiting lists, waiting times rising back to the crisis levels of 1997, and beyond.
In an NHS which already spends less, and has fewer doctors, nurses, beds and less equipment per head of population than any comparable country, things are set to get even worse.
Of course this is no oversight or accident: it’s part of the conscious neoliberal attack on public services and public spending. Osborne had choices in 2010 and 2015, as does Chancellor Phillip Hammond: their choice is to reduce spending and scale down the size of the state, to minimise taxes paid by the rich and big business. While £1.2 trillion has been found or created from the public purse to rescue the banks in 2008, the NHS is stuck with a frozen budget and rising costs, forced to seek ways to cut services and “save” £22 billion (less than one sixtieth of the bank bail-out) by 2020.
And that means the scale and quality of local services are at risk up and down the country, in big cities and shire counties, where now the definition of “local” extends in some areas to a 60-mile radius, with sick patients facing long journeys over rotten roads with minimal public transport options as services are “centralised” to remote hospitals and centres.
Smaller local GP practices across the country face being uprooted and moved miles away to new “hubs” where they can be required to work alongside other GPs to deliver primary care “at scale” – regardless of the extra journeys for patients seeking appointments.
None of these plans that were hatched up last year in secretly-drafted “Sustainability and Transformation Plans” (STPs) takes any heed of the transport problems of moving services, especially for the most vulnerable patients. Indeed the reality is often carefully concealed in happy-clappy rhetoric with empty promises to deliver a full range of personalised services to patients in their own homes – again without addressing the logistical, staffing and financial issues of doing this.
Every one of the 44 STPs covering England echoes the same theme, arguing that “prevention” and health promotion targeting smoking, alcohol abuse and obesity, and even promising action on social isolation, housing problems and employment, will magically and with almost instant effect reduce the need for hospital care, saving millions of pounds without costing a penny.
The STPs were set up as strategic planning bodies in the hopes of accelerating and forcing through the “efficiencies” centralisation and cuts in quality and staffing that are required for the NHS to come anywhere near bridging the looming gap of £22 billion between actual funding and the level funding should have risen to by 2020 to meet the rising costs each year.
NHS England boss Simon Stevens has made clear he sees the STP structures as a means to overcome the “purchaser provider split” first created by Thatcher’s NHS changes in the 1990s, widened by Labour in the 2000s and now deepened into a chasm by Andrew Lansley’s disastrous Health & Social Care Act in 2012: but Stevens also wants to create bigger planning units that make it possible to “override local vetoes” and force through unpopular cuts and closures.
Perhaps it’s the awareness that so many of the STPs have developed into wishful thinking and abstract flights of imagination rather than hard-edged plans for cuts that has prompted Simon Stevens and the regulator NHS Improvement to write to the leaders of the 44 STPs calling on each of them to develop a “credible implementation plan” to turn proposals into action and reconcile them with contracts and financial targets.
So all of the STPs which have talked abstractly of centralising services will need to come clean on which services will be downgraded or closed, and how far patients will need to travel to access care. All of the plans for primary care “hubs” need to be costed, all of the staffing issues addressed of delivering any of the promised “proactive” services to patients who are not yet even ill, and replacing hospital services with care “in the community”.
The hundreds of millions in unresolved social care deficits, which cannot be rolled over year by year, and which should have been addressed by the STPs, will also need to be revealed, cuts proposed and the consequences discussed.
The mood will have to change from happy-clappy to nasty as the Nasty Party’s cash squeeze is translated into cuts. So all over England millions of people who felt coming up to March 4 that maybe they did not need to fight for their NHS will soon begin to realise that they do.
That’s why it’s so important to go forward from March 4 to build a new, even broader, popular movement in defence of the NHS, and demand properly funded, publicly-owned, publicly delivered, publicly accountable health and social care. In place of means-tested charges for social care we need proper tax funding and the cheapskate home care companies and care home owners should be nationalised and care integrated with the NHS, and delivered free at point of use.
We need movements in Tory areas strong enough to rock the complacency of councils and MPs, and force them into action. Already we have seen Tory councils and councillors, and Tory MPs from some of the worst-hit rural areas beginning to speak out. These include Sarah Wollaston, a Devon MP who chairs the Commons Health Committee and who has scathingly demolished government claims of £10 billion extra for the NHS. She faces closures of community hospitals in her patch: many other rural Tory MPs face the same or similar issues.
In fact as a party largely made up from older people and with strong pensioner support, it’s worth noting that the Tory squeeze on the NHS across the winter has left thousands of Tory voters and members stuck on trolleys waiting for A&E treatment or waiting weeks for a GP appointment. We need to be playing on this contradiction and using every lever we can to force local Tories to break ranks and pile pressure on May’s government: the campaign must not restrict itself to appealing to the labour movement, although that is also extremely important.
The March 4 demonstration has won varying levels of support from 16 national unions – and from John McDonnell, Jeremy Corbyn, many Labour parties and union bodies across the country, as well as the People’s Assembly and the National Pensioners’ Convention, and every serious local campaign on the NHS. There is even a solidarity march in Truro for those who can’t face the marathon journey to London.
This kind of response is what we in Health Campaigns Together hoped for when we took a massive chance last October and as a small meeting voted to call a national demonstration. We believed then, as has proved to be the case, that the financial squeeze would trigger a winter crisis in the NHS that would animate even the Tory press.
Of course we know that the right wing press – the Daily Mail, Times, Sun and Telegraph – have another agenda when they criticise failings in the NHS. Their answer is not our demand for proper funding and action to reverse the Lansley reforms, scrap privatisation and restore the service as a properly planned, comprehensive service, free to all at point of use, funded through taxation. For the right wing of the Tories, the answer to the NHS crisis is even more privatisation, despite all the evidence of disastrous failures of private contracts for support services and clinical care, and a massive expansion of private health insurance.
But this belief that health insurance can deliver comprehensive cover to those willing to pay is a grotesque delusion: in Britain the private insurance and private hospital sector has shied well away from any idea that it should provide any emergency services at all. Nor do they train any doctors or nursing staff, and most private hospitals employ only skeleton crews at best, with surgeons and nurses brought in session by session, and not present over night (many of them also work in the NHS).
The private hospital sector’s business and focus is exclusively based on elective care, as uncomplicated as possible, and insuring relatively prosperous people of working age who are the least likely to get sick and demand treatment. When things go wrong in private medicine, their patients are put into ambulances … and packed off to NHS hospitals, the only ones equipped for complex care.
The private health care sector is not in the least bit interested in the patients who make up the bulk of the NHS case load: the very young, the very old, the chronic sick and the poor. There is no profit to be made from insuring them, and they don’t have the money to pay for the care they need.
In other words ,any Tory complacency on the state of the NHS is based on huge misconceptions or downright lies which can and must be challenged. If the NHS is pushed by May’s cuts into a state of collapse, with repetitions and worse of the winter crisis of 2016/17, nobody is safe: we all need the NHS.
We have always known that one demo, however big, won’t shake the government, and won’t reach the wider spectrum of people we need to worry ministers. But we can’t wait till the next general election in the hopes this will solve our problems: it won’t — especially if we have not already stemmed the damage, and forced a let-up in the funding squeeze. So we need everyone returning from the march to get organised more seriously and vigorously in every locality, urban or rural.
We have already reached into towns, cities and villages going well beyond the previous network of campaigns: the March 4 demonstration has struck a chord, and been raised already on our behalf by people we have yet to meet. Now we need to go further again.
We need to use leaflets and social media as widely as possible as we seek support from faith groups, community groups, ethnic minority groups and from local workplaces, football clubs, colleges and universities.
We need invitations to speak at union branches, TUCs, political party meetings and social clubs – and anywhere willing to hear us, seeking support, funding and practical support in writing to local politicians and local news media.
Everywhere we need to be lobbying local Clinical Commissioning Group meetings, council meetings, trust board meetings, local councillors and MPs with one simple message: to get NHS bodies to admit publicly that there’s not enough money in the pot to keep our NHS intact; to get councils to use what powers and influence they have to challenge STPs, and resist and obstruct cuts and closures; and to get MPs of all parties, but especially Tories, to bang again and again on Theresa May’s door demanding a change of policy.
In the process of this there is scope to develop more detailed discussions about the development of a coherent policy for the Labour Party and a strengthened opposition fight that builds on Jeremy Corbyn’s rejection of the politics and policies of austerity. We can have debates over ways to tackle the Private Finance Initiative, roll back privatisation, reinstate our NHS – and what policies need to be developed to tackle the causes of ill health and preventable mortality.
We can discuss how much more should be spent on health and social care, and how the extra money should be gathered into the pot of general taxation – whether this is action to collect the estimated £120 billion a year of tax that is evaded, avoided or not paid, increased taxation on the rich, an increase in income tax, or simply slowing the pace of plans to pay off the deficits that linger after the banking crash.
But it’s much more than a debate: and any who may hope that the campaign can be reduced to propaganda and the long-established narrow approach of the sectarian far left will be disappointed. This is far bigger than a chance to recruit a few more members.
We don’t so much want to debate with Tories, rather we hope to build a movement that can bully them into a retreat. If the Labour Party is savvy enough to recognise that this can help win back lost working class support and weaken the Tories, all well and good: but the movement can’t wait for them if they can’t respond quickly.
We have a real chance to go forward, and to win, at least on the limited, clear demands of no cuts, no closures, no privatisation. And if we can win on that, new possibilities arise. It’s a challenge we must try to rise to: because without us fighting now we could suffer the historic setback of losing our NHS.