There was an almost audible groan of most of 1 million-plus NHS staff at the news of the election of a majority Tory government, amid near-universal expectation that this would trigger an immediate and massive acceleration of the privatisation process in the NHS, along with cuts and closures of NHS hospitals.
The subsequent scrapping or reduction of many of the key performance targets for hospitals, and the decision to stop the National Institute for Clinical Excellence drawing up guidelines on minimum nurse staffing levels seem to underline these concerns.
But the limited scale of Cameron’s majority, and the delicate plight to which five years of Tory spending freeze has already reduced the NHS – together with Cameron’s Thatcher-esque “one nation” post-election victory speech – give reason to doubt whether the damage will be as rapid and brutal as many have predicted.
As the election campaign was waged, NHS and foundation trusts and some Clinical Commissioning Groups (which hold local NHS budgets to commission health care) were unveiling billions in deficits, with dire predictions for huge targets for more “efficiencies” to balance the books this financial year.
Straight after the election, NHS chief executive Simon Stevens indicated a determined effort to get on top of these problems by replacing the “unsustainable provider regime” that triggered the battles over Lewisham Hospital with a new “success regime”. He sent regulators and private management consultants in to try to tackle financial crises in Essex, Devon and Cumbria, although we have yet to see what magic they may weave. Changing the vocabulary is not likely to resolve the problems.
Cash-strapped commissioners in Essex are yet again leading the charge towards the rationing of health care with a cap on spending on vasectomies: on previous occasions rationing has always begun with treatments where the private sector is happy to step in – for a price.
Cameron seems to have believed the polls, and expected that this backdrop would be a nightmare for a new minority Labour government or for a coalition, rather than a mess his ministers need to deal with.
But now, with a majority of just 12, and memories of the way in which John Major’s larger majority rapidly disappeared, Cameron can ill-afford for ministers or NHS England to pick a series of fights over hospital closures in areas where Tory MPs or even Tory councils may feel obliged to side with local communities to defend NHS services (and votes).
NHS cuts were a battleground that cost Major vital support in the mid-1990s as gleeful campaigners won over apparently unlikely backing from backbench Tories.
Cameron himself, and even Health Secretary Jeremy Hunt (previously on record as wanting to abolish the NHS) have both duly continued to insist on their commitment to the NHS. During the election campaign Cameron was even forced to go further than Labour in promising extra financial support to help Simon Stevens bridge the predicted £30 billion gap between George Osborne’s plans for NHS resources and the cash needed to maintain current levels of services between now and 2020. However there is as yet no word on where the money might come from.
Opinion polls have consistently showed that most Tory voters (and UKIP too) are opposed to privatising NHS services. It’s self-interest: Tory activists, many of them elderly, are also protective of the levels of local services and opposed to cuts and closures. They know how little they could expect from the private sector.
Cameron has continued after the election to insist that he wants to see a 7/7 provision of NHS services, something that only a publicly-provided service could offer, although there are of course huge questions of where the funding would come from, and whether 7/7 working would make any sense.
There is also the looming prospect of a battle with health unions to establish 7/7 working by scrapping the ‘unsocial hours’ payments that have for more than a decade been a key component of the Agenda for Change pay structure – and a major component of the pay of many crucial health workers.
This is important when we bear in mind another major problem facing Cameron: five years of frozen pay, or below inflation pay increases for NHS staff have slashed the real terms value of nurses’ and other professional staff pay by upwards of 16% since 2010, with no relief in sight.
This has run alongside a constant increase in pressure of work, the frustration of constant demands for “efficiency savings”, unfilled vacancies, and reliance on less qualified staff, leaving a dwindling band of qualified staff with a rising workload. To make matters even worse, the effects of a cutback in the training of nurses and other health professionals is already sending NHS trust managers scurrying once more around the EU nations seeking to recruit nurses – and as far afield as Australia for paramedics.
Growing staff shortages have brought the soaring bills for agency staff that were recently highlighted by Simon Stevens, who complained that the NHS was being “ripped off” by agencies.
But the reality is that the NHS cannot continue to deliver acceptable quality services without an adequate supply of trained staff – and that there are real limits on how many attacks on pay and conditions can be carried through while the shortages remain at this level. Nurses are leaving NHS staff jobs to work for better pay and much less stress for agencies. And there’s not much the NHS seems able to do about this unless there is a major rethink.
Pressures on GPs have also reached the level that it is becoming almost impossible in some areas to recruit new partners for local practices, and a growing proportion of new doctors qualifying to work as GPs are opting to work as freelance locums or salaried staff to minimise their obligations.
Partly as a way to get around this, there are moves to promote the idea of 24/7 access to “health care” in the form of computer apps or phone links to disembodied “doctors”: but we already know that the 111 service and its predecessor NHS Direct were not very successful at diverting demand away from hospitals.
Whatever the marketing gurus may hope to achieve, for most people 24×7/365 day services means access to real services in A&E and emergency care when required. Such a system is in no way congenial to a private sector that has always focused solely on cherry-picking safe, uncomplicated elective and outpatient services and diagnostics – leaving all the messy, costly, risky and long-term responsibilities to the public sector.
The private sector in any event is for the most part struggling to make any profits even from those contracts it has picked up from the NHS, and the list of highly visible private sector screw-ups keeps growing.
A recent round-up in Private Eye confirmed suspicions that few of the big name companies are making any money. Serco, of course, has pulled out of contracting for clinical services after a series of costly and high-profile failures, while Circle, which pulled out of its failed contract to run Hinchingbrooke hospital earlier this year has published accounts which show its losses increasing last year to £20m on income of £110m.
Virgin Care too has been running at a loss, as have Care UK, Optum (part of the American giant UnitedHealth), the country’s biggest private hospital firm General Healthcare Group, and rival private hospital chain Spire healthcare. Only the Australian multinational Ramsay Healthcare averages a small £7m profit.
To make matters worse for the privateers, there have not yet been the expected big wins of new contracts for private providers. In one instance, in Sussex, where an irresponsible commissioning group tried to hand a contract for Musculoskeletal Services to a consortium led by BUPA, BUPA felt obliged to pull out, on the basis that they did not want to be held responsible for the financial collapse and closure of A&E services in two local hospitals.
The only private sector providers who are coining in the profits so far are the management consultancies – McKinsey, KPMG, PwC, Ernst & Young and many more – who are effectively now running much of the commissioning of services and many of the struggling trusts as well. But they simply drain money from the NHS, while dreaming up new ideas that consistently fail to address the real problems it faces.
So Cameron has little choice but to keep an NHS running – even while the chaos created by Andrew Lansley’s legislation, which established over 200 CCGs, each required to put a growing number of services out to competitive tender, continues to undermine any rational planning or collaboration. Stevens seems determined to assert more central control as the only way to deliver the £22 billion of “efficiency savings” he claims he needs to stand any chance of balancing the books by 2020.
With so many different trajectories of change, it’s clear that campaigners need more than ever to scrutinise the commissioners and local trusts. They need to work together and with the health unions, local communities and the wider working class movement and share information and expertise if vital services are to be defended.
Cameron, the Tories and the marketisers are by no means invincible, but the fight needs to be waged now to build a real fighting force to defend the NHS rather than pursue conspiracy theories divide itself over historical arguments.
In the battle against the Major government’s cutbacks united and broad-based campaigns, often backed by the health unions and by Labour, were able to win important victories. But of course today’s unions and Labour Party are politically and organisationally far weaker than they were then, and the left too is much more divided.
Can today’s campaigns unite in the same way as they did in the 1990s against a common enemy, or will our divisions make Cameron look much stronger than he is?