In 2014, Simon Stevens was appointed chief executive of NHS England.
In October 2014, NHS England published a FIVE YEAR FORWARD VIEW FOR THE NHS.
Although no public response was invited, nor opportunity to respond provided, Defend our NHS York and Leeds Keep Our NHS Public have collaborated to produce the following analysis and critique of the document, in the hope of contributing to the crucial debates about the NHS in the run-up to the General Election in May.
RESPONSE TO THE FIVE YEAR FOWARD VIEW FOR THE NATIONAL HEALTH SERVICE
The historical and social significance of the National Health Service (NHS)
Social change is now so rapid that it is hard to make sense of it let alone learn from it. The opening sentence of this report is a measure of that. The first words: ‘The NHS may be the proudest achievement of our modern society’, while seeming to assert the value of the NHS, fail to reflect its full significance.
Our pride in it is beyond doubt – no ‘may be’ about it. It is impossible to overstate the importance of the NHS: It needs to be spelled out that the NHS is an evolutionary social development which has changed the lives of everyone in this country, “our country”, and peacefully effected change in “our” society so profound that we do not recognise it, or fully remember the circumstances in which it arose.
For example, optimism in 1945 was less important than the clear-eyed determination to eradicate pre-war squalor, ignorance and fear: of sickness, of the cost of medical treatment and of the loss of livelihood that it entailed.
Only those people now well into their seventies can remember that the sacrifices of war had not been left behind in 1945: despite rationing, food and fuel shortages were critical and the scars of the blitz still dominated urban landscapes. The pre-war housing crisis had been exacerbated by the devastation of the air raids. The country, “our country”, was bankrupt.
It is against that background that the present condition of the NHS should be considered. It faces new problems and challenges, of course, but its condition cannot be described as critical, still less insupportable, considering that we have recently managed to meet the costs of two long-drawn-out wars (supported by both major political parties), and the bail-out of irresponsible bankers – all money down the drain.
By contrast, the relatively small amounts needed to maintain and develop the NHS have beneficial effects, now as in the past, not just on the nation’s health, but on its prosperity, as the post-war experience shows. The NHS creates employment and expertise in many fields as well as health. It increases the disposable income of the general population by removing the burden of personally financed health care. (c.f. The USA). A healthier, longer-lived population is almost the least of the benefits of the NHS. We cannot afford to waver in our commitment to universal health care – publicly funded and provided.
TACKLING CHANGING HEALTH ISSUES IN A CHANGING WORLD
“Our values haven’t changed, but our world has”. The two cannot be separated. Our values have changed, not in relation to the almost universally beloved NHS, but in response to changes in the world. The new challenges of longer life have still to be fully addressed at all levels. As for health problems “of our own making”, once problems reach the proportions cited in this report (60% of adults are overweight or obese, 30% misuse alcohol, 20% still smoke) they can no longer be seen solely as personal, but as public issues. (C. Wright Mills).
It is beyond the remit of the NHS to deal with such complexity: it derives from the unchallenged pressures and persuasions of a commercialism and consumerism so insidious and pervasive that they fail to attract the critical analysis and counter measures that are needed even in relation to life-threatening issues like obesity and alcohol misuse.
The Stevens Report perpetuates this myopia. It is the business of government to deal with this situation, not the NHS. Some may say that this sounds like a ‘Nanny State’ approach. In fact such measures would attack the infantilisation of everyone (by mass advertising and the mass media) which is breaking the back of the NHS. The propaganda lessons of the Second World War need to be redeployed in improving national health. Clever merchandising skills cannot be left solely in the hands of those selling us stuff that does us no good, simply for profit
The task is too huge and important to be left to cash-strapped Local Government, elected mayors and an overburdened NHS: it is a major national issue for Central Government. If the NHS is to be able to cope with the challenges of longer life expectancy, a benefit for nearly all of us, the adult population needs to be enabled to behave like adults: the commercial interests profiting from unhealthy life-styles can only be challenged effectively by Central Government. It is now the case that local authorities have a statutory responsibility for improving health, but it is responsibility without power, the reverse of the case with the media.
As in the 19th century, preventive health measures are more important than medicine in improving the nation’s health; then it was sewage and water supply; now it is tackling the problem of over-consumption: problems of affluence not effluence : just as damaging.
The NHS – A healthy workforce promoting public health?
The NHS is urged in the report to improve public health by promoting health in its workforce and making itself an exemplary employer. As well as setting a standard for all employers, it suggests that sickness absence would be reduced saving a great deal of money. But the report overlooks the unhealthy effects of long working hours and excessive shift work that are the result of 20,000 unfilled vacancies in the NHS. These cannot be unrelated to deteriorating pay and conditions of work as a result of pay freezes and cut-backs. These government created conditions do not help to make the NHS an exemplary healthy employer. Better food on night duty etc. cannot solve the problem.
Parallel to this, while emphasising the central role of the care sector in future health care, the report ignores the plight of care workers in the private sector on less than the minimum wage (150,000 according to King’s College Care Workforce Research Unit) dependent on food banks for a healthy diet, while 370,000 are on zero hours contracts in the name of ‘productivity’. (Norman Lamb, Care Minister). But has anyone ever met a ‘hard up’ private care home owner or shareholder? The report does not consider these issues in urging a better integrated Health and Social Care system.
FUNDING ISSUES AND ORGANISATIONAL CHANGE
The five year forward plan betrays the same lack of incisiveness (even blandness) throughout: an evasion of the nub of the problems the NHS is valiantly facing.
While generously recognising the successes it has achieved against the odds (e.g. quoting improved cancer and heart disease outcomes; the Commonwealth Fund Report’s endorsement), the Stevens report fails to make explicit some of the main causes of the major funding challenges confronting it, e.g. the extortionate costs of the Private Finance Initiative (PFI), the implementation of the 2012 Health & Social Care Act and competitive tendering, still less to consider ways of dealing with those problems. The longer standing administrative costs of operating the ‘internal market’ within the NHS (the 1992 purchaser/provider split) are similarly ignored.
An issue nowhere addressed in recent reports, including this one, is the costs the NHS has incurred as a result of out-sourcing ancillary services, the first wave of privatisation dating back to the 1980s. In every area of Britain, there are people who have made private fortunes delivering services that were previously in-house (cleaning, supplies etc. etc.). It is arguable that causal links can be made between that process and infection in hospitals. Agency nursing is another hugely costly means of dealing with staffing shortages related to erosion of pay and conditions for full-time nursing staff.
These key financial drains are ignored. They make an enormous contribution to the financial predicament of the NHS, and they mark only the tip of the iceberg of the costs of more recent privatisation.
The 2012 Health and Social Care Act has unleashed unprecedented, hugely expensive, unnecessary and unpopular changes on our comprehensive and publicly funded NHS. This was done by a coalition government after the dominant partner had promised no top-down reorganisation in its election manifesto; the junior partner had pledged commitment to the public NHS and its Party Conference voted against the Health and Social Care Act weeks before it colluded in passing that Act. No one outside Parliament voted for that legislation; It was an attack on democracy itself. The results go unmentioned in this Report.
Health care, correctly delivered, is not and never can be a commercial undertaking. All diversion of tax funded resources (e.g. into profits, dividends, bonuses, etc) represents treatment denied and is directly harmful to patients and injurious to the common good. Recognition of this is the basis of public support for the NHS.
While omitting mention of all these issues and developments, calculations of billions of pounds are bandied about in this report, figures plucked from the air with no firm link to reality. When the NHS was founded, the average wage was roughly £5 a week. Inflation takes care of most debt. We can afford the NHS, especially if more effort were to be made to retrieve unpaid taxes – another factor omitted from this text. We spend the least on healthcare as a proportion of GDP of all G7 countries (as Stevens acknowledges) and have the second lowest number of hospital beds per capita in Europe. Ring-fencing a budget that doesn’t meet our needs is meaningless.
Overall, the problem with this report is its failure to grasp the full social and economic significance of the NHS in all its complexity. The range of its activities is enormous: ‘from cradle to grave’ it attempts and largely succeeds in meeting the health needs of a large, complex, rapidly changing, post-industrial society as it invents and responds to new technology and evolving culture and life-styles. Depth analysis should encompass finance and economics, cultural factors, and management, especially of change and cross-boundary working, logistics ….the list is endless. Miraculously, the NHS deals with all these factors and it WORKS.
The 5 year plan is unconvincing because it skims the surface of the issues it does address, and fails to raise the core questions. Perhaps the omissions are unsurprising, given Steven’s roles in the private sector over the previous two decades.
The structure of the NHS prior to the Coalition Government’s Health and Social Care Act:
Following the changes it now looks something like the diagram below, and in the words of David Hunter, Professor of Health Policy and Management at Durham University (to whom we are grateful for the use of these slides) – a complete dog’s breakfast, as the NHS performed well already, the changes increased bureaucracy and the case for competition, which the coalition increased, remains unproven.
THE WAY FORWARD – AN ALTERNATIVE VIEW
The NHS is now becoming a key election issue as the public begin to realize what is at stake, and the media can no longer afford to turn the other way. Cameron has been forced to say he did not understand the Lansley Bill and its implications. A look at the second diagram explains his incomprehension.
Direct assault on the NHS has always been politically impossible – better by far to introduce ‘reforms’ that sound as if they are rising to the challenge (even if the Prime Minister himself doesn’t understand them). Few will be taken in by Steven’s representation as the saviour of the NHS. Contrary to his assertion, experience with adult social care suggests that further contracting out of NHS services is likely to see exponential growth, unless stopped by the electorate. We must repeal the Health and Social Care Act, increase NHS funding to meet the growing need for health care, stop unsafe closure of services to save money, renegotiate crippling PFI debts and give a fair deal to NHS workers. If Simon Stevens’ heart is in the public sector can we hear him pledge support to these objectives?
Whatever the legislative strategy of the incoming government after the 2015 General Election, its first goal must be to address the worst excesses of the 2012 Act: This can be done without reconfiguring the whole of the new system (a process that would be eye-wateringly expensive, utterly demoralising for NHS staff and damaging for patients).
The following points are the simplest and most easily accomplished measures that will ensure the survival of the NHS as a publicly provided service:
- Responsibility for health care should revert to the Secretary of State.
- The 2013 regulations which restored the pressure on CCGs (rejected during the passage of the Bill) to put services out to tender should be cancelled. (Any Qualified Provider).
- The power and centrality of Monitor should be curtailed.
- GPs with private, commercial health company interests should be ineligible for membership of CCGs (or anything that replaces CCGs)
- The private, commercial health company interests of MPs and Peers should be publicised.
- The clause allowing NHS hospitals to raise up to 49% of their income from private care should be revoked and replaced by the previous arrangement.
- The impending US/EU Trade Agreement, the Transatlantic Trade and Investment Partnership (TTIP), should, at the very least, exempt Health Care from its measures (as is the case in Canada).
- Private Finance Initiatives (PFIs) should be swiftly renegotiated and measures adopted to reduce the excessive NHS debt that has resulted from them
These suggestions would restore the essential nature of the NHS, and give a breathing space where longer term reforms could be allowed to develop in full consultation with service providers and users.
The interest and concern that has been generated by the present government’s destructive policies can be harnessed to inform genuine public debate about the future of the NHS, involving lay and professional opinion, a process which could re-invigorate democracy itself.
The NHS is the crowning achievement of British democracy, along with the defeat of Fascism. We must not now let it fall into the hands of anything-but-democratic multinational corporations.