John Lister looks at the situation facing the NHS:
A U-turn last week by an increasingly uncertain government underlines the deep divisions within the Tory Party over the EU Referendum next month.
David Cameron was forced into a significant retreat in Parliament, when he abruptly agreed to support a proposal to exempt the NHS from the looming EU-US trade treaty (TTIP), avoiding an embarrassing defeat on the Queen’s Speech. This has been rightly celebrated by campaigners.
But it is unlikely to fully protect the NHS as long as key elements of the NHS are being subjected to competitive tender and outsourcing to private providers.
And in every other respect the threat to the future of local services and to the NHS as a universal and comprehensive service is still real – and growing.
The financial stranglehold of George Osborne’s austerity squeeze – designed to reverse all of Labour’s decade of increases in NHS spending by 2020 – is now tightening on the NHS.
We are in the sixth year with a budget virtually frozen in real terms, and falling in relation to rising pressures since 2010. Trusts are expected to reveal a minimum of £2.7bn deficits from last financial year – and must implement measures this year to drastically rein in spending, and establish “financial balance” next year.
With acute trust deficits averaging a staggering £15m, this level of savings cannot be achieved in most areas without painful cuts: and with key performance targets already being missed, longer waiting times, and a worsening crisis in mental health services, any new spending cuts are likely to further undermine the quality and effectiveness of the NHS.
David Bennett, former chief executive of the regulator Monitor, is only the latest leading figure to highlight the fact that NHS spending is “about two thirds of the average of comparable health services elsewhere.” As a result, the ability of the health service to drive through further savings on the level required is in question. Leading US systems advisor Don Berwick has also pointed out that running a universal service on just 7 percent of GDP is an “experiment”.
Chris Hopson, chief of the trusts’ body NHS Providers has warned that without more money up to 50 hospitals could have to close.
The trusts are indeed expected to carry the vast bulk of the burden of achieving the colossal £22 billion of savings which NHS England chief executive Simon Stevens set as a target by 2020.
NHS England has now declared that up to £15.3 billion of that total is to be squeezed from front-line trusts – with £8.6 billion in increased “productivity”, and £5.7 billion from “demand management” measures that aim to cut trusts’ caseload (and income) by restricting use of services.
Most “demand management” policies are notable for the lack of any evidence of their effectiveness so far – with emergency admissions still increasing in number across the country, despite repeated assurances that they would begin to fall.
However the measures that do restrict demand are the explicit rationing measures and exclusions of some specialist services such as IVF treatment, and ever-tightening restrictions on elective treatment including cataract, joint replacements, hernia and other non life-threatening conditions.
This is designed to push some people with the means to do so to pay for private treatment rather than wait until their condition becomes an emergency, or severe enough for the NHS to take action. This in turn undermines the NHS, promotes inequality and leaves many with the greatest needs unable to access care.
Most of a further £6.7 billion “savings” is expected to come from more years of real-terms pay cuts for long-suffering NHS staff. This has been imposed nationally by the decision of George Osborne, and is one of the factors underlying the junior doctors’ dispute – but has an increasing impact on the ability of trusts to recruit and retain medical, nursing and other professional staff.
Of course where they have gaps in key frontline staff, the trusts are then driven to bring in agency staff – even while NHS England is trying to cap their spending on this and squeeze down agency rates. Meanwhile the staffing crisis remains unresolved.
Balance the books
The “savings” required are truly massive. So the immediate agenda in almost every area is cuts to bring spending back into balance – coupled in some cases with the use of skilled external accountants who will advise on how best to cook the books to minimise reported deficits and maximise apparent income.
A new regime is being imposed to drive this increasingly urgent agenda. NHS England has begun overriding the Health & Social Care Act which established over 200 Clinical Commissioning Groups as the main commissioners of care.
Instead NHS England has imposed a new, unilateral and top down reorganisation, carving England into 44 “footprint” areas, in which for the first time since the 1990s commissioners (purchasers) are required to collaborate with the providers – in drawing up 12-month and 5-year Sustainability and Transformation Plans (STPs) to “transform” services and balance the books.
Simon Stevens has also now insisted that within each of these areas trusts have to make much bigger “savings” than some have been planning.
Forcing through unpopular decisions
In addition he has decreed that where there are controversial decisions to be made (notably over “the disposition of hospital services”) there could be a “pooling of sovereignty” between trusts and CCGs, to establish “combined authorities” with powers to overcome any potential “veto” or resistance.
Older observers, perhaps nostalgic for earlier organisational structures, will see the STPs as a resurrection of the old “Area Health Authorities” established in the 1970s, long before the competitive market and putting services out to tender were even thought about.
But these are not going to be kindly, collaborative bodies.
The purpose is much more sinister: this is the old technique of taking controversial decisions as far away from local communities as possible, so that there will be little if any accountability or engagement with communities who face the loss of local access to hospital or other services.
Footprints = cuts
In practice all 44 “Footprints” and their STPs mean cutbacks and bed closures, as shown by the STP planning to cut 500 beds in North West London – equivalent of at least one of the two hospitals (Ealing and Charing Cross) targeted for closure in long-running controversial plans.
Not every Footprint will focus on bed reductions or hospital closures, but many will. Each STP will vary slightly in form, but each of them will need to make significant changes, and make big reductions in services if budgets are to be balanced by the end of next year.
Some of these reductions involve long and painful journeys. Plans have just been published for the merger of Peterborough & Stamford Hospital, floundering in unpayable PFI debts, with Hinchingbrooke Hospital – which is 22 miles away, and still reeling from the deficits left behind after its period disastrously managed by Circle.
There’s fresh talk of reconfiguration of services between Bedford and Milton Keynes Hospitals – 18 miles apart – with discussion of using services up to 58 miles away.
Similar plans for long-distance “reconfiguration” and centralisation of A&E services are being drawn up in many other areas. Chris Hopson has queried the need for separate A&Es “as little as 14 miles apart” – but not explained how patients are supposed to access more distant hospitals.
The STPs – which allow for no public consultation, and sideline both the CCGs and the Trusts, which do have an obligation to consult on changes of service are clearly a mechanism to do unpopular things at great speed with NO local accountability or consultation.
They are to be finalised in the summer and implemented from October, whether local people agree or not.
The plans are being hatched up now behind closed doors. They will be sent to NHS England by June 20.
Opposition – at last
At last we have a vocal challenge to this steamroller of cutbacks from Labour’s ranks with junior shadow health minister Justin Madders writing in a powerful blog that:
“I have asked a number of Parliamentary questions about the footprints and some of the few facts these have revealed include that the footprints and leadership teams do not have legal status or legal duties and will not have the ability to borrow.
“This means that if these bodies do come to the conclusion that certain local services will have to go as part of a blueprint, there may be no public consultation on such decisions and no formal mechanism to challenge them.”
The gloves are off: straight after the Referendum, the NHS will become embroiled in a cuts and reconfiguration frenzy that will hit almost every part of the country.
Campaigners need to be ready: threatened hospitals and services that are not actively defended could be axed.
Split the Tories
We need to undermine the government will to drive through the austerity agenda. We have to force more splits in the Tory ranks, to pile pressure on Tory MPs whose local hospitals are under threat.
If promising signs of active Labour Party engagement on this bear fruit, it could mean we can build really strong, united local campaigns: we have to stop these cuts, and demand an end to the austerity squeeze on the NHS.
We must insist that any cost savings are based on scrapping the costly and wasteful market system created by Andrew Lansley, which wastes upwards of £5 billion a year – not on bed closures alongside worthless promises of ‘alternative’ services that are unproven and lack any real resources.
A universal health service like the NHS should be cannot be delivered on Osborne’s meagre funding of 7% of national income (GDP) or less: we must demand a reversal of the cuts that have forced us into this situation, and push spending back up as a share of GDP to at least the level achieved in 2010.
A campaign linking campaigners, unions and the Labour Party could build into a mass movement to defend our NHS and roll back privatisation and the wasteful market. It’s a winner: let’s back it!
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More on the latest carve up of the NHS here.