I enjoy listening to a range of podcasts from different political viewpoints. One topic that came up recently – albeit as a sidenote of the episode in question – was the NHS. The speaker complained of “The absolute veneration of the NHS. It would be political suicide to even think about breaking up the NHS, or thinking about any other way of structuring the health service in the UK.” Listening to MPs praise the NHS was described as kowtowing, sickening and ‘I felt like I had to take a shower afterwards.’
And yet I wonder. For all the political comment that the NHS is taboo and cannot be touched, the fact remains that the NHS has repeatedly been the subject of political restructurings, and in the past twelve years has been suffering from major under-funding and a failure to train new and retain existing staff.
The NHS is not taboo
Restructuring
The NHS was most recently restructured on 1st July 2022. Yet Scotland, ahead of England on this particular version of NHS structure, has already announced that it will be replacing its version of what England is about to do.
This is the biggest legislative restructure since the 2012 reforms, but restructuring the NHS is not a decadal opportunity. Politicians do it all the time.[1]
There was the NHS Plan in 2000, introducing Private Finance Initiatives (an idea disastrously borrowed by Labour from neoliberalism). Then in 2002 the NHS was reorganised, replacing District Health Authorities with Strategic Health Authorities and Primary Care Trusts. In 2003, new contracts were agreed for GPs and hospital consultants, changing the way that services were delivered. Later in 2003, there was another reorganisation with the introduction of Foundation Trusts, which was opposed by many Labour MPs. In 2004, the Healthcare Commission took over from the Commission for Healthcare Improvement. In 2006, four years after the introduction of SHAs and PCTs, the number of SHAs was reduced from 28 to 10, and of PCTs from 303 to 152.
In 2009, a new health and social care regulator – the Care Quality Commission – replaced the Healthcare Commission set up only 5yrs previously and merged it with the Commission for Social Care Inspection and the Mental Health Act Commission. Then in 2012, the SHAs and PCTs created only ten years earlier and modified after four years were abolished completely. In 2015, Greater Manchester was given devolved powers over healthcare, becoming the first English region to have full control of its health spending. The next year, the Cities and Local Government Devolution Bill was passed, “with potentially momentous implications for the NHS.” In the same year, the regulator of NHS foundation trusts, Monitor, was merged with the Trust Development Authority to form a new organisation, NHS Improvement. A new contract was agreed for junior doctors, amidst bitter division and industrial action. And new measures were announced in an attempt to reduce NHS spending.
Moving on to 2019, a new contract was agreed for GPs. And in 2022, a new Act was passed which restructures the NHS around Integrated Care Systems and strengthens the control hold by the Secretary of State.
Funding
The NHS is being steadily, knowingly, unnecessarily, inappropriately underfunded.
Tony Blair helped. He provided a lot more money to the NHS, and healthcare improved. There used to be over 50,000 people waiting over a year for hospital treatment, and patients waiting up to two years for heart surgery.[2] In 1999 a 38-year-old patient died whilst waiting for cardiac surgery. Labour changed that, because it was unacceptable (it is a shame that sick people dying because they were refused benefits under Conservative ‘welfare reform’ has not been seen as equally unacceptable!). But the improvement seen under Labour has been eroding under Conservatives, and it continues to be cut away. If the NHS were truly an untouchable domestic goddess, it wouldn’t be failing the way that it is now. It would continue to be funded at a level that makes it a world-leader for outcomes, not just for outcomes-per-pound-spent. The fact that the NHS remains so efficient despite political meddling, serious underfunding and excessive burdens placed on staff is a testament to the hard work and dedication of all our NHS staff – but it doesn’t mean that they, and the NHS itself, are not in trouble.
When Conservatives took power, they inherited an NHS in which 97% of A&E attendees were treated within 4 hours. Now, it’s eleven percentage points lower, and it’s worse for the major units that treat the most serious issues. Conservatives inherited a waiting list of 2.3 million; it was 4.4 million before Covid hit, and now it’s 6.3 million.[3] The target for non-emergency, non-cancer treatment hasn’t been met since 2016, and in some places only half of patients get their first treatment within 18 weeks. The target that 85% of suspected cancer patients should start treatment within 62 days of being referred has not been met since 2013.[4] This is not a Covid issue. It’s an issue of 12 years of underfunding and failure to train and retain staff.
The World Health Organisation recommends a minimum of 3 hospital beds per 1000 people. France has 5.84; Germany has 7.91. The UK has 2.45 and falling.[5] Spain, Portugal, Greece and Italy have more than us. The total number of beds needs to increase just to stay level with the population, let alone reach minimum global standards, let alone compare with our peer countries.
Health issues increase in a more unequal country,[6] and inequality is what neoliberal policy creates.[7] Health issues also increase in a growing and ageing population, which we have. But the number of full-time equivalent permanent GPs and nurses has fallen, especially in England, when to even keep level we need the number to increase.[8] That’s the Conservatives’ responsibility – they have had twelve years to be training GPs and improving retention.
It shouldn’t be a surprise to anyone that the UK is the only developed country where the initial spike in labour market drop-outs from Covid has persisted.[9] A key hypothesis is that this is because people who have become ill – whether from Covid or from other conditions that have been neglected due to Covid – have been unable to return to the labour market, and this may include older workers who have chosen to take early retirement. This is, after all, what happens when you don’t treat people with serious treatable illnesses: they remain seriously ill, and seriously ill people can’t work. Whatever the Conservatives like to tell you, it remains the case now as in Beveridge’s day that illness can destroy the capacity for work until that illness is cured or its symptoms adequately relieved; and working whilst ill continues to make people more ill rather than cure illness. There is a major economic case for a functioning health service that is free at the point of use, but the Conservatives – and even Labour – refuse to see it or make it.
Privatisation
The NHS isn’t taboo. Politicians can cheerfully choose not just to under-fund it and repeatedly reorganise it, but also to privatise it. But healthcare is the very opposite of a system suitable for privatisation.
Healthcare relies on teamwork, cooperation and collaboration. The specialist in hospital A needs to be able to get a second opinion from the world leader in hospital B. But does your private employer really want you sharing your hard-gained expertise and world-beating knowledge with your competitor down the road?
Someone has to train these doctors and nurses. Every private hospital would rather poach the best staff and train nobody. Private medical businesses paying higher salaries (because they’re not paying for the cost of early-career practitioners and trainees) can attract our best medical practitioners away from the public service that trained them, without offering any training placements in return. The next generation of staff has to be trained by someone, and if the government pays for the training then the public should get to keep the staff it trained.
Healthcare relies on providing the most appropriate treatment according to the need, not the cheapest or according to ability to pay. But profit-makers want to provide the cheapest treatments to the easiest patients; they don’t want to deal with the complicated patients or the ones that need higher-than-average care. So they cream off the cheap and the easy, and abandon the rest or throw them back to the NHS – and then claim to have better outcomes, when the reality is that they have healthier patients.
Profit-makers aren’t interested in the most appropriate healthcare, but the most profitable. If they can scare you into taking scans that are very unlikely to reveal anything, or to take medicine that is unlikely to do anything – whether good or bad – then they might as well do so, because they cream a profit off the top. But at the same time, if you need an expensive intervention and you’re reliant on insurance rather than direct payment then your insurer will do what they can to get out of paying for you. This is why the USA has such terrible outcomes for such excessive expenditure. The USA approach is the last thing we should want, yet its where our politicians seem to be looking.
Some people argue that competition improves performance – ignoring the immediate drag on performance of carrying out a competitive tender, advertising services, and raking off a profit. But we don‘t need to hypothesise; we can ask the data. In the UK, an annual increase in 1% point of outsourcing to the for-profit sector is robustly associated with a 0.38% point increase in treatable mortality.[10] In Italy, mortality rates rose following a period of outsourcing, with higher avoidable mortality rates in areas with a higher proportion of private sector delivery.[11] Spending more on public delivery of health services led to a faster reduction in avoidable mortality, whereas spending more on private health services did not reduce avoidable mortality. Just privatising the cleaning can cause harm to health: outsourcing cleaning services is associated with greater incidence of MRSA, fewer cleaning staff per hospital bed, worse patient perceptions of cleanliness and worse staff perceptions of availability of handwashing facilities.[12]
Continuity
Healthcare relies on continuity of care, not the cheapest possible provider which so divvies up the nursing and healthcare that the person who brings my food, changes my sheets, takes my basic observations and monitors my toileting and water intake are four different people and none of them are the nurse who is actually supposed to be nursing me during my stay in hospital, and none of them help me when I need help to get to a toilet or to use a cheap cardboard commode, none of them tells me where the shower is or even that it’s okay to use the shower given my cannula or biopsy plaster, none of them tells me that I won’t get served food because I wasn’t there when the food order came round, and none of them can tell me what I should be eating given the reason that I’m in hospital or how to get food when I missed the order.
Continuity means having a family doctor who you go to even with your trivial issues because what matters is that she knows you and your family and can spot the early warning signs; or ask about, and therefore learn from, what happened with your previous issue; or combine information from different family members to identify a genetic disorder. Continuity means that it is your GP, not a nurse or healthcare assistant, who takes your bloods and so she realises how hard it is to take blood from your veins, and she also notices that you have many bruises and hyper-youthful skin, and she combines this information with the reason you came to ask other questions that lead to a diagnosis of Ehlers-Danlos Syndrome, hypermobility type.
Continuity means not having to explain your issues at every single appointment, and it means having a doctor who has built up a picture of you over time and heard the different ways you have of explaining your issues and uses the combination to get to the nub of the problem, rather than being misled by one poor turn of phrase. Continuity means people with serious conditions or acute illnesses are not passed off to a physician associate with even less training than a nurse, who can’t prescribe even a blood pressure medication let alone discuss how to treat neurological symptoms, help someone with a deteriorating condition or separate the acute gastro issues into those with cancer and those who just have dietary problems.
A public good
The problems isn’t that politicians can’t change the NHS. It’s that they have changed the NHS for decades, gradually taking it away from its founding principles, hiding their actions behind claims that it isn’t possible to do anything to the NHS, all the while restructuring, underfunding, failing to train, driving staff out of healthcare through intolerable strain, and putting public services in the hands of profit-seekers at the cost of people’s health and lives. Labour at least increased funding to the NHS, but under Blair they also supported costly privatisation in the false belief that this would save money at the cost of something other than the health and lives of patients and staff alike.
The NHS is not sacrosanct. Public provision of healthcare, free at the point of use, remains a public good and continues to be a sound economic and moral investment.
The NHS is Christian
This blogpost was sparked by some comments I heard on a Christian podcast. The argument made was that the NHS is post-Christian, because it is based not on Christian values but on doing the opposite of whatever Hitler did. Where he bumped off the weak and disabled, we do the opposite; where he was racist, we will not be racist; where he would winnow the weak and do away with them, we will protect them and provide a welfare state.
But where did we get the idea that Hitler was wrong? From Christianity. The idea of healing the sick and helping the disabled is not new to post-WW2. It has been amongst Christians for centuries. The idea that healthcare should be given according to need, not ability to pay, is not new. Christians have believed it since the start of Christianity.
The idea that a job might actually be a vocation and that people aren’t robots to be divvied up into ever smaller, narrower ranges of tasks with no relational component is profoundly Christian – following the model of the God who became man; who built long-lasting relationships; and always had time for the smallest, the least important, the most minor of issues.
The NHS isn’t post-Christian. It is entirely Christian, and we should support its proper funding and investment.
[1] https://www.nuffieldtrust.org.uk/health-and-social-care-explained/nhs-reform-timeline [2] https://www.gponline.com/gps-verdict-10-years-blair/article/656158 [3] https://www.nuffieldtrust.org.uk/news-item/how-do-waiting-times-for-nhs-planned-care-vary-across-england [4] https://www.nuffieldtrust.org.uk/resource/cancer-waiting-time-targets#background [5] https://www.kingsfund.org.uk/projects/nhs-in-a-nutshell/hospital-beds [6] Wilkinson R and Pickett K (2009) The Spirit Level: Why more equal societies almost always do better [7] Ostry J, Loungani P and Furceri D (2016) Neoliberalism: Oversold? FINANCE & DEVELOPMENT 53(2) [8] https://www.nuffieldtrust.org.uk/news-item/is-the-number-of-gps-falling-across-the-uk#the-headline-trend-in-gp-numbers [9] https://www.ft.com/content/c333a6d8-0a56-488c-aeb8-eeb1c05a34d2 https://www.ft.com/content/63dcc4d1-8b53-4110-bd44-10e3d1d98585 [10] https://www.thelancet.com/journals/lanpub/article/PIIS2468-2667(22)00133-5/fulltext [11] https://pubmed.ncbi.nlm.nih.gov/23024258/ [12] https://pubmed.ncbi.nlm.nih.gov/28012431/