My previous blogpost, Health In Our Time, celebrated the transformation of ordinary working lives by the Labour Government’s creation of the National Health Service in 1948. Political battles marked its inception and do so to this day. Some of these battles centre on arguments about the allocation of scarce financial resources between diverse national claims and institutions. But the overarching framework is an ideological one, with competing ideas about the role and legitimacy of that new post-war welfare state. These ideological and institutional battles were fought out both between and within the primary political parties, and the victories and defeats depended most on which particular interest had control of the levers of government. But these various competing groups were also significantly constrained by the popularity and universality of the NHS, which meant that its (mostly Conservative) adversaries treated it with great circumspection for many decades, while constantly trying to undermine it and reduce its power as a unified national institution. In the 21st century these attacks have become more strident and have coincided with a costly and aggressive health pandemic, to the extent that we might say that the NHS is currently facing an existential crisis, as calls arise yet again for its reform.
‘Crisis’ and ‘reform’ are labels that have defined debates about the NHS from the 1950s to the present day. Reform is always a weasel word in British political discourse, for it often conceals a wish and intention to destroy and replace, rather than renew and improve. I am reminded here of an old friend and academic colleague (sadly no longer with us) Professor Howard Elcock, a specialist in British local government and politics, also a sometime elected councillor for the then Humberside County Council. Mention NHS reform to Howard and you would be lucky thereafter to get a word in edgeways. He once published an article on these issues satirically entitled ‘Reorganise! Reorganise! Reorganise!’, because he could not abide the impulse of every new Government and new Health Secretary, of whatever political persuasion, to attempt a wholesale reorganisation of the health system. This normally meant in the history of NHS reform that one botched and ineffectual reorganisation would be replaced by another, with administrative and financial disarray the most common outcome. This phenomenon was most marked in the 1980s when the vogue for so-called New Public Management produced attempts to introduce competitive market principles into the processes and procedures of government, to make administrators into entrepreneurs, to create ‘smart’ government i.e., which would always be required to do more with less (less money, less staff, less state of the art buildings and technology.) A concomitant effect was to change the language of public services. In the NHS this meant treating doctors and other health service staff as ‘managers’, who must seek ‘best value’ for patients who would now be renamed as ‘customers’ or ‘consumers’ rather than ‘patients.’ Another significant effect was to reduce what was always termed the burden of taxation, deliberately subverting the notion of essential and universal public services.
This empty sloganising had little real effect when demand for health services was expanding exponentially, given that the age profile of patients was also constantly increasing. But the pressures created by these developments, both on ever-rising costs and on professional staff resources, both in primary care and in the hospital system, made the NHS vulnerable to the idea that public services of this size needed the shot in the arm that commercialisation and market principles would supply. As it happens, the first attempt to apply these ideas to the NHS came when the Health Secretary under Margaret Thatcher was Ken Clarke, once an exact contemporary of mine at Caius College, Cambridge in the early 1960s. Clarke’s appointment might be viewed with some irony since he has been regularly and closely involved at times with British American Tobacco, responsible for products that have caused innumerable deaths worldwide, and created heavy burdens on health services). His contribution to these burdens in 1990 was to introduce market principles into the NHS in the form of an ‘internal market’, against the advice of the medical profession.
This rushed and ill thought through reform was killed off by New Labour. But New Labour under Tony Blair and Gordon Brown made significant contributions to the introduction of competitive and privatising elements into the operations of the NHS. If the first ‘Trojan Horse’ in NHS history was Nye Bevan’s concession in 1948 that private practice could be continued within the framework of the NHS, the second one was arguably the acceptance of limited commercialisation and private sector investment under the Blair governments of 2001 and 2005, most fully realised in the Public Finance Initiative (PFI). PFI was a framework to get the private sector to fund the capital costs of constructing new public service buildings like schools and hospitals along with the long term maintenance of such buildings. New schools and hospitals were undoubtedly needed, as large parts of these public estates were old and badly rundown. PFI offered the prospect of spanking new buildings on the cheap. Taxpayers were doubtless pleased to be treated in a brand new hospital, while their children capered happily through attractive new school buildings. But the complexities of PFI contracts initially concealed undesirable outcomes: the high borrowing costs had to be met over very long periods, while long maintenance contracts were both expensive and poorly regulated. Many of our contemporary smart-looking new hospitals are still paying off considerable debts to private contractors There were even cases where the costs of paying for these new buildings and maintenance contracts meant that hospital managers could not afford the staff they needed to make them work.(we might be reminded here of the recent Nightingale Hospitals, hailed by Conservative Ministers as a brilliant piece of emergency provision, when in practice they were scarcely used ‘white elephants’ because the exigencies of the NHS meant that no trained staff were available to staff them.) James Meek sets out bluntly Labour’s responsibility: “It was Labour that introduced Foundation Trusts, allowing hospital managers to borrow money and making it possible for state hospitals to go broke….It was Labour that handed over millions of pounds to private companies to run specialist clinics that would treat NHS patients in the name of reducing waiting lists…It was Labour that brought private firms in to advise regional managers in the new business of commissioning”. Meek concludes that “If the Conservatives are dismantling the NHS, it was Labour that loosened the screws”. (Meek: 2014, pp 162-3). The dismantling soon began, first under the Conservative-Liberal Democrat Coalition government, then under subsequent Conservative Governments led by Cameron, then May, then Johnson.
The NHS Now: A Dismal Decade
This might seem to be a gloomy heading, during a time when across the country, people for a time regularly came out to stand on their doorsteps and clap their hands in recognition of the heroic efforts of NHS staff at all levels to cope with the appalling pressures of the Covid19 pandemic. The Prime Minister himself would also be on the steps of 10 Downing Street, leading such applause. But this was this Prime Minister, Boris Johnson, who almost immediately denied these same staff a real-terms salary increase; a Prime Minister who has presided over a shocking array of misjudgements and delays over the past two years, and who led a secretive and possibly corrupt process of awarding to private sector companies (often linked to Conservative donors and allies) extremely lucrative health service contracts. He has refused to respond to calls from all parts of the political spectrum for an independent inquiry to ensure public accountability for many extremely ineffective appointments, and to establish that lessons are learned which could avoid serious pandemics further down the line. This is a Government which has repeatedly trumpeted claims of the world-leading nature of the British response to what is a global crisis, but almost never refers to the fact that the UK has the largest number of pandemic deaths in Europe, and in this respect is genuinely a ‘world leader’. While our research scientists have been universally praised for their work on vaccines, they have repeatedly found themselves ignored or contradicted in public decision making and management by our political leaders. These leaders cannot, of course, be blamed for the pandemic itself, and political leaders everywhere have struggled with the management of the most serious public health crisis for a century. But we in the United Kingdom have the misfortune to have, at this most critical time, the most incompetent, uncultured and self-serving set of political leaders in our lifetimes. This ineptitude is compounded by an all too apparent absence of moral compass.
Unhappily for us all, this deeply unattractive bunch have no absence of political ambition, and a major part of this ambition is to continue and extend the relentless war on the post 1945 welfare settlement that the Conservative party has waged since its initial battles with Nye Bevan. This campaign began with the Thatcher regime, whose acolytes have served in several 21st century administrations. They seized their opportunity in the dreadful Conservative-Liberal Democrat Coalition Government of 2010, when the hapless Liberal Democrats made no real effort to prevent Andrew Lansley (the Health Secretary) from getting through Parliament the 2012 Health and Social Care Act “that sent the NHS into the spiral it is now in, combining extra competition with swathes of additional bureaucracy… an attempt to realise the Thatcherite promise of marketisation” (Toynbee and Walker, 2017, p.54). From then on, health services could be commissioned from and provided by a confusing array of private and public organisations, the NHS itself just one of many possible competitors. Most NHS funding was allocated to Clinical Commissioning Groups, essentially clusters of GP practices, generally quite unfitted for financial management responsibilities, and so quickly prey to the lurking private sector consultancies that could provide such expertise.
If the Blair-Brown Labour Governments had endorsed similar (though much more carefully regulated) principles, at least they ensured a significant degree of funding, attempting to bring UK spending up to the European Union average. But the Cameron-Clegg Coalition and subsequent Tory administrations (Cameron, May) pursued an austerity financial strategy. This starved the NHS of much needed funds, and professional staffs of income increases, laying the ground for the very significant shortages of crucial health service professionals, (at all levels, but especially hospital doctors, nurses, and GPs) that now so restrict the ability of the NHS to meet rising medical need and demand. There are now 100,000 unfilled vacancies for doctors and nurses, while waiting lists stand at 6 million (Toynbee, Guardian, 23 November 2021.) A recent Institute for Fiscal Studies report predicted an increase to 11 million within a year, rising to 15 million by 2025, unless there are significant increases in NHS funding of capacity; while a Nuffield Trust study and numerous other sources warn of an existing financial deficit of £5 billion, with an increase of an extra £7 billion annually needed on top of current spending (Observer 08 August 2021). Meanwhile, as Meek predicted “the more for-profit companies become involved in the NHS, the more public money will leak out of the health system in the form of dividends’ (Meek, 2014, p.181).
While the unlamented Lansley has long gone, even darker and more dismal prospects now loom for the NHS under the Johnson Government’s crudely ideological leadership. Yet another reorganisation and ‘reform’ is being proposed under the NHS Health and Social Care Bill now on its way through Parliament (turn in your grave again, Howard!). This Bill was based initially on proposals designed by Simon Stevens, the former Chief Executive of NHS England (though before that he worked for United Health, one of America’s largest private health companies, and a major private sector global player in health services provision and contracting). The new reorganisation would replace the 2012 commissioning systems which had opened up all NHS provision to private tenders, compelling NHS bodies to compete as if in an open market. The new legislation will create (in England) 42 so-called Integrated Care Systems (ICS), each with its own budget and governing board, and intended to allow local mergers and community cooperation, while integrating the provision of local health and social care services.
But these changes (seemingly laudable in principle) are most unlikely to be realised in the face of the Government’s deliberate intention to control these new processes and institutions, and clear determination to give private providers privileged access to governing ICSs, and to increased contracting opportunities. The Bill places direct executive authority and control with the Health Secretary, a direct contradiction of the initial professes aim to give powers and control back to more localised arrangements. A major stated objective is to integrate health and social care, long advocated by health professionals and specialists. But nothing in the Bill or accompanying documentation says how this will be achieved, who will lead such a process locally, how any changes will be funded, or how private contractors, abetted doubtless by political cronies, will be prevented from cherry-picking lucrative contracts while ignoring less profitable areas of need. In short, this further reorganisation and ‘reform’ will be bent and shaped by an ideological narrative, rather than by the basic needs and imperatives of a highly prized and admired national institution, as it struggles to meet the ever-expanding health needs of a diverse and ageing population. The provisions on social care are to say the least, both opaque and controversial.
As health service users, concerned citizens, and potentially powerful voters, we need to find it in ourselves to reject the siren voices of private provision, for that way lies a fragmented health service and a two-tier system of health provision on the deeply flawed American model. We also need to be ready to accept the responsibility for ensuring adequate funding for our own preferred model. This means being ready to give our resources to support the NHS through an appropriate level of taxation, rather than haplessly lining the pockets of private enterprises who for the most part are neatly captured in the title of James Meek’s critique of the privatisation of our major public services: Private Island: Why Britain Now Belongs To Someone Else. Let’s do all we can to resurrect the fine visions of William Beveridge and Aneurin Bevan, resisting the attacks by those who are motivated by little other than self-interest.
Sources
Meek, J. Private Island: Why Britain Now Belongs To Someone Else (Verso, 2014)
Toynbee, P., and Walker, D. Dismembered: how the attack on the state harms us all (Guardian Books,2017)
The Kings Fund is a highly respected independent think tank specialising in health issues. It provides invaluable detailed briefing on the current Health and Social Care Bill (www.kingsfund.org.uk)
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