Britain - NHS: 60 years of "not enough", and they're still cutting

Jan/Feb 2008

This year the National Health Service will turn 60 years old. PM Gordon Brown has not waited for the official celebrations due this summer. He is already boasting about the "world class" NHS, which is better and bigger than ever before, thanks to its staff, but mostly thanks to Labour and especially thanks to him.

He chose to make his first major speech of the new year on the subject of NHS, reminding everyone that the NHS had, in fact, been the government's main priority since he took over. Of course. However, many of his "new" announcements of screening tests and even the NHS constitution "setting out patients' rights and responsibilities" were not new. Much of the screening already takes place, but the problem which already arises is that there is not enough funding for it.

A year ago, the NHS was still in a bit of a mess. There were persistent financial deficits in many hospitals and in primary care, "reconfiguration" meant more cuts and closures, and the rebellion continued among staff against the plans to cut the number of Primary Care Trusts (PCTs), sack thousands of workers and oblige trusts to "commission" (buy) services from private health care companies.

By contrast, 2007 has ended with the NHS in surplus, apparently by as much as £501m, and the "return to financial balance" according to chief executive, David Nicholson. But this is hardly surprising, given that the PCTs have, in the meantime, undergone major "reorganisation" (i.e. major cuts) and in fact many of the staff who were sacked in hospitals which had deficits, remain sacked and the wards and units which were closed at the time, remain closed.

Despite the assertions of Brown and his acolytes, there are still not that many happy stories to tell about the NHS. After all, what positive spin can be given to the consequences of closing a maternity unit under the so-called "reconfiguration" , or the drastic shortage of junior doctors' training posts and the failure of the new computer system for selection of candidates? Especially in the context of a crying need for more hospital specialists and GPs!

But there is probably nothing more indicative of a health service in deep crisis, than the on-going and seemingly intractable scandal of so many deaths from hospital acquired infections, whether it be methycillin resistant Staphylococcus aureus (MRSA), Clostridium difficile, or another less notorious bug. Never mind, though, because Gordon Brown has announced that all the hospitals will be given a "deep clean", whatever that means.

Then to add to it all, in these days of nigh hysteria over "identity theft" the fact that hundreds of thousands of NHS records, which have been undergoing a seemingly endless computerisation (another failed PFI project!), have gone missing, is yet another scandal. There is something highly symbolic about the fact that when new technology is actually installed in the NHS, which could improve diagnosis, the continuity of care, and follow up, the tools of this technology should get lost by some private subcontractor or another. Yes, no matter how high-tech, nothing is immune from being sabotaged by the profit motive. So no, not much to celebrate.

That said, when Blair resigned in June, he took with him the highly unpopular health secretary, Patricia Hewitt, whose back many were glad to see. Brown has brought in the ex-postman turned gamekeeper, Alan Johnson, in her place. This is an important job for Johnson, so he apparently spent his summer reading up the history of the NHS, ending this brief respite by offering NHS staff a below inflation, 2% pay deal - an issue which has yet to be resolved. No change there then!

The Brown-Johnson-Darzi plan

For obvious reasons, the NHS is politicians' biggest football. If they do not appear to be performing well with it, they will always pay for it in the polling booth.

So, almost as soon as he got his feet into Blair's shoes, Brown appointed Professor "Lord" Ara Darzi - a kind of "superhero" surgeon - as a parliamentary under secretary of state at the Department of Health to join his "government of all the talents".

Whatever Darzi's skills as a doctor may be - and these are certainly impressive - the point is that he really fits the bill insofar as he is a supporter of the government's "reforms". In these days of celebrity culture he cuts a bit of a dash, and will, Brown hopes, provide an excellent cover for continuing his government's policy of more privatisation under the guise of "choice" and more cuts, under the guise of "reconfiguration". Like any good surgeon about to amputate a limb, Darzi will explain quite plausibly how much better off the patient will be without it.

Darzi tends to begin his speeches by saying "I am a doctor not a politician". But he is most definitely a politician, seasoned and well-baked. He has been sitting in the House of Lords ever since 2002 after being knighted by the Queen for his "services to medicine and surgery". He knows the score very well by now and is obviously quite willing to be used by Gordon Brown to sell the supposedly "last phase" of NHS "reform".

This ties in with the other reason why Darzi's appointment is significant. Brown realises that one big criticism of the NHS is that it is not run by doctors and nurses - often cited as the reason for many of the problems, including the near epidemic of hospital acquired infections. Putting a doctor (and, what is more, a super-doctor) in charge of the government's health reform programme might seem a clever answer to this. What is more, Darzi had already shown his worth by producing a review on "Healthcare for London: a framework for action" at the request of NHS London, the all-London strategic health authority.

To give an idea of what sort of solutions the final phase of Labour's reforms have in store for the NHS, it is worth looking at Darzi's proposals for London, which have been more spelt out, but are in essence the same as what he has outlined for the whole of the NHS, in his Interim Report published this October and called "Our NHS, our future". Darzi is meant to complete his review and recommendations for some "fundamental changes" by the time of the NHS birthday this coming June.

While the government keeps saying that people should have "choice" and that they should have "personalised, local services" close to where they live, what is proposed is fewer and more specialised hospitals, and a new kind of service - which Darzi chooses to call polyclinics. These polyclinics would incorporate the functions of GPs, of hospital outpatient departments (with some consultants on duty and many investigations available, including X-rays) as well as some treatments and "minor" accident and emergency services. For London he proposed 150 of them, at an estimated annual cost of £3.1bn.

There are a number of assumptions involved in these proposals. For instance it is asserted that the population no longer needs big district general hospitals (DGHs) with all the diverse specialities and services, nor the beds, since hospital stays are so much shorter, and medical science and technology have progressed so much. We are healthier, our needs are different, but more complex, there are computers which can do next to everything, etc., etc. This surely means that the general hospitals can be closed?

Of course, new technological advances can, in many instances, shorten the time people need to be in hospital and shorten the duration of treatment and recovery. But that assumes that the funds are there, to pay for all the equipment and the computers which are needed and that the appropriately qualified personnel are available as well. This latter point is all the more important because nurses are being asked to do even more of the jobs which doctors used to do and no-one is doing the jobs that nurses used to do! What is in effect being proposed is the removal of a comprehensive hospital, long before people have stopped needing it!

The government's argument continues: a number of highly specialised hospitals dotted around London (under Hewitt these were referred to as "super hospitals") would be able to "improve outcomes" for patients because the expertise would be concentrated, instead of spread thin, or maybe even absent - as is often the case in district general hospitals today. The specialist hospitals would expand on what already exists in London i.e. hospitals like Great Ormond Street for children, Moorfields for eyes, the Royal Marsden for cancer, etc. Of course, but they would need to expand by an enormous amount - and this is not spelt out - if they were now the only places to obtain specialised care.

Downgraded general hospitals, now referred to as "local hospitals" would still care for "non-complex" inpatients and do day-case surgery and rehabilitation. It seems that these will be a bit like what used to be called "cottage hospitals" in the past. These local hospitals would offer emergency care on a 24/7 basis, but would not have a full intensive care facility. Anyone requiring high level critical care would have to be transferred to a "major acute hospital".

These major acute hospitals would be the only hospitals with a full range of facilities for emergency admissions. We are told they will provide "highest clinical standard" care (fewer, but better ...) and have stroke units and trauma units, for instance. But they would also need significant expansion and a lot more qualified staff if they were now having to take transferred emergencies from local hospitals.

As for the so-called independent sector treatment centres (ISTCs) which were launched in 2002 - by private healthcare companies - the idea is that they would still provide the non-urgent elective procedures like cataract, hip and knee replacements - and would be called "elective centres". Indeed, the question is asked whether they could maybe do more?

Preparing the way for more shark species

Some of these proposals might sound quite reasonable. For instance, polyclinics, staffed with salaried GPs and specialists, as well as all the technicians, laboratory workers, therapists and social care specialists sound like a marvellous idea. A patient sees the doctor, gets sent for tests, goes back with the results and the GP speaks to the specialist next door, who sees him straight away and books him in for your treatment. If it is a minor procedure it might be done there and then. All in the same day. What is more, these clinics would offer extended opening hours and the majority of Londoners would be just 1-2km from such a clinic.

Yes, it all sounds like progress, until the real "why" and the real "how" are examined.

What is immediately obvious is the scope that all of this new healthcare structure offers to the private sector to come in and offer services for profit. In fact Darzi uses the US as his example time and again, and in a more recent "International Health Summit" invited a speaker from the US company, Kaiser, which runs polyclinics over there, to make the case.

Actually it is already happening in primary care as a result of the reforms begun in 2006. Now Darzi wants 100 new GP practices and 150 new health centres (polyclinics) in England (over and above those in London). But the fact is that contracts for clinics and services run by so-called "alternative providers of medical services" from the private sector are already being considered as the only option in primary care. And GPs are justifiably afraid that they could squeeze out traditional NHS GPs.

It is all the more ironical as this is being done, among other things, in the name of "a more personalised health service." Today, it would be true to say that NHS GPs are among the few NHS personnel who actually provide a really "personal service"!

Indeed, Darzi's proposals seem to have been especially designed to upset general practitioners. They are also being told that they must work extra hours at night and weekends at the risk of losing their bonuses. He seems to realise that the present system of general practice would be undermined by polyclinics, and "alternative providers of medical services" and so he says that possibly GP practices could integrate themselves in some way with the polyclinic/medical centre.

If all of this was envisaged as a proper restructuring of the health service under public ownership and control, to make it work much better, then general practice and GPs themselves, would certainly have had to come under the spotlight. And there would be no way round upsetting GPs, in this case, either. Because the GP system was always an inbuilt flaw in the NHS, right from its inception, since GPs refused to be salaried employees of the government. So, as "independent contractors" they were never properly integrated into the NHS, to provide a really "joined-up" service. But as a consequence they were able to play a vital role in keeping patients out of hospitals and de facto rationing the service - because another fundamental flaw in the NHS has been its chronic under-funding.

If the government's aim really was to modernise and improve the quality of the health service it would turn general practice into a salaried public sector job first. But if its aim is merely to provide openings for the private sector - which would compete with GPs by offering salaried positions to doctors in polyclinics - then it would be quite happy to leave GPs to stew in their own juice, if need be, which seems to be the case. Of course, it is an expensive stew!

Not too hard to figure it out

The question of "why" all these proposed changes at this stage (provided one has accepted the fact that a "world class NHS", top quality care for all, etc. is all hyperbole), is actually quite simple.

All in all, the latest "Darzi" version of the government's reform plan would require a lot more investment in the NHS - even in basic infrastructure. Yet at this "phase" of Labour's NHS polices, the funding for the NHS is being cut significantly - with only a 4% annual increase in resources over the next 3 years. So there is obviously something not so straightforward going on behind all the glossy reports, reviews and public consultations and incredibly ambitious plans.

An admission by the NHS chief executive David Nicholson brings us back to the Hewitt-conceived "NHS Reconfigurations" which were launched in 2006, and which precede and prepare the ground for Darzi's plans - and are probably his starting point.

"Reconfiguration" , in government parlance, means the "redesign" of the NHS to concentrate key services in fewer hospitals. No matter if these services were needed in more hospitals!

Nicholson justified this at the time as follows: these "60 reconfigurations of NHS services, affecting every strategic health authority in the land" were "to squeeze out overcapacity that contributed to the NHS's £512m deficit in the last financial year." This is probably news to most people, because these deficits were said to be due to "bad management" and nobody talked about "overcapacity" at the time! They were in fact caused mainly by the excessive payments which trusts were obliged to make to the private sector for PFI projects and the like.

But of course, after Trusts had been forced to sack their workers and close wards and as a result, with difficulty, at last balance their books, how could they admit that the capacity they had just cut was actually essential? And that now they have to turn patients away? This is exactly what is already happening.

The example of the so-called Outer North East London NHS exposes the problems behind Reconfiguration and Darzi alike - and very graphically also reveals the main motive as cost-cutting on the one hand and opening up opportunities for the profit sharks on the other. These motives were denied consistently by health minister Hewitt while she was in post.

In 2006, a reconfiguration plan based on Hewitt's "Fit for the future", was put forward for the health service covering 4 boroughs of outer north-east London - Barking and Dagenham, Havering, Redbridge and Waltham Forest. It later transpired that this was due to "marked financial stresses, particularly in two Acute Trusts". This reconfiguration proposed a number of options, but these all boiled down to downgrading to a "local" type hospital, one of the three big district generals involved - either Whipps Cross, or King George, or the brand new PFI Queens Hospital in Romford.

However, the all-London strategic health authority was obliged to request a "review of the clinical case for change" - which was completed in October 2007 - because - to quote the review "the plans have caused major unrest amongst both the public and their representatives on councils and in Parliament, with the focus of concern centring on the fear of closure of an A&E department in either Whipps Cross or King George hospital. There is deep scepticism about the ability of the community to cope and little belief that the proposed changes are for patient benefit rather than just a book balancing exercise".

This is true. And in fact the Tory MP and ex-party leader, Ian Duncan-Smith was himself very much involved in the campaign to stop the downgrading of Whipps Cross! But what is also true is that these Trusts were all already struggling with too few resources. Professor Alberti, the author of the review, explained that "All are struggling to reach the 98% operational standard (i.e. the standard that 98% of those attending A&E should be admitted, transferred or discharged within 4 hours of arrival) and face major problems with providing experienced cover for 24/7 services."
Basically Professor Alberti's recommendation was that the consultation on changes in these boroughs should start again from scratch and be based on improving the service rather than cost-saving. The point was made that "we are concerned that at present there is a lack of capacity in both the acute sector and community to undertake the major changes envisioned."
Yes, lack of capacity, not overcapacity! This review is damning, because it exposes the government's reforms for what they are - that they bear no relation to need and are really about cutting capacity - even where it is already stretched, and cutting costs at patients' expense.

The changes have been put on hold and new consultation is meant to start in January 2008. That said, it appears that this part of north-east London is going to have to do without one of its acute hospitals anyway, and this is likely to be the relatively new (built 16 years ago) King George hospital in Goodmayes. This is one thing Alberti admitted. Even if the health service in these boroughs is already inadequate, the resources are not going to be made available for improvements and in fact there is no choice but to make cuts!

The question now is, where would the cuts be least damaging?

Moving maternity services and other acute services to the new Queens hospital, which is what is proposed, will require an immediate increase in capacity there. In fact, Queens was built with 5% fewer beds than the hospitals it replaced, even though an increase in the population it serves was already underway, due to the Thames Gateway housing developments. In other words, the situation may have been calmed by a few honest words from a learned professor and his team of experts about what was behind this reconfiguration, but the government is not going to offer the resources needed to provide "top quality care" in these hospitals and PCTs. But maybe the great grandchildren of the present residents will get some polyclinics, (if Lord Darzi does not fall out of favour with this government, or the next), given how long it will take to build such temples of excellence and find the staff for them!

The poor are still being killed off prematurely

It is necessary to go back and deal with, in no uncertain terms, one particular and much-used justification for the current NHS reforms, even if it is obvious that this is just one more cover-up for cuts. And this is the assertion that the population is so much healthier today.

The government itself commissions research on health inequalities so it is in prime position to know better than anyone how bad the situation is in this respect and that it has got worse in the last few years!

In December 2007 The Department of Health published the data on life expectancy at birth and infant mortality, given that it has a target to improve the mortality and life expectancies by 10% by 2010.

The latest data shows that a man in Manchester can expect to die 10 years earlier than a man living in Kensington and Chelsea - 73 years compared to 83.1. In 1995-7, the gap was less (70 years in Manchester compared to 78.2 years in Chiltern - which at that time had the highest life expectancy.

This is a very big gap. And it implies that there is a big class difference in the health of populations, which 60 years of the NHS has not managed to narrow. But of course only getting rid of the class system can eradicate this difference.

However, in the meantime, the factor that seems most associated with this lower life expectancy is the shortage of GPs in the areas where people are dying prematurely.

Yes, in this day and age - when the NHS is apparently again "the best in the world" somehow the old entrenched problems are still entrenched! Who would have expected, after so many years of trying to "equalise" the service provision, that an increasingly non-uniform provision would be offered - and that this provision would still be largely dependent on old poor-rich boundaries?

Yet this gross inequality - not surprisingly - is not given priority in the Darzi report. However it is mentioned. And it seems that it will be used as a justification to bring in private providers to fill the gaps. Even if what is really needed are dedicated public-minded health workers who will really and truly provide personal care to these deprived areas with a commitment to the long tern and without any commitment to profit.

The mystery of the vanishing ISTCs

The experience of private sector provision so far, is pretty mixed, and of late, tailing off somewhat, if the independent sector treatment centres (ISTCs) are taken as an example. So far there are 23 of these operating and to make the market attractive, the government has exempted then from national tariffs until 2008, so they have been able to charge the NHS 11.2% on average more than the NHS equivalent cost.

Shortly after Alan Johnson was appointed health secretary, the rumour started circulating that the second wave of ISTCs would be scrapped. In fact Johnson said he would probably scrap some of them, but not all. Whether the ISTC programme is actually being scaled back or not is doubtful, despite the griping over it in the financial press.

This alleged "setback" for ISTCs and the private health sector in general seems more like a temporary lull, which was inevitable, and will probably last until the current reforms are all in place, especially since it is hard to see what else the reforms can be aimed at other than creating enormous new opportunities for profiteering in the future.

If ISTCs have not been making worthwhile gains lately then it is probably because some district general hospitals are outdoing them, having improved their ability to do day cases in a lot of instances. In other words ISTCs have difficulty competing profitably with the NHS at the price. But what are the reconfigurations going to do? They will cut NHS capacity for such operations and the private sector will be able to fill it. This is not even taking polyclinics into consideration, because they are so far not exactly feasible.

The other way that the private sector is in for a big boost is via the policy which is being forced onto PCTs - so called "world class commissioning" which will ensure that they buy more services from the private sector over the coming years.

A document which the DoH prepared but has not published called "ISTCs, the story so far" apparently explains (according to the Financial Times) "that without a sufficiently large private sector, there will be no competitive tension to drive down cost, raise quality and improve accessibility and the market will not be large enough to be self-sustaining."

Part of this reasoning is economic nonsense, but the market is soon to become much, much larger, provided that the proposed new reforms go ahead. And that will be "problem solved" for all concerned, except patients who will have less for more. This is especially the case, since so far, ISTCs are not at all integrated into the NHS which means that there is no assurance of any kind of continuity of care or after-care. Which may well be recognised as a problem, but tackling it could pose a few problems given the conflicting aims of the two sectors.

The unions kow-towing to Brown

The final Darzi review for fundamental change in the NHS is due out next June. But in the meantime the reconfigurations of local services are going ahead, in preparation.

Affected local communities continue to protest. For instance, those campaigning against the closure of a maternity unit at Eastbourne district general. If this closure goes ahead, women in labour would have to travel to Brighton or Hastings, along a single-lane winding road for at least 30 minutes but more likely one hour. Complications would make such a journey life threatening, for both mother and baby.

This is why ordinary people have been protesting vociferously ever since specific reconfigurations were announced and indeed these protests still continue all over the country, even if they seldom get more than local media attention.

Labour figures and even the NHS trade union organisations however, have been conspicuous by their absence, usually justifying this by a refusal to protest alongside a Tory. However, on the 3 November last year, finally, a national demonstration against the cuts and closures in the NHS was meant to take place in London. Initially it was called by the "NHS Together Alliance", which includes the doctors' and nurses' professional association as well as the trade unions, and was billed as a "demonstration to defend the NHS". But surprise, surprise, it was taken over by the largest public sector union Unison, and was turned into a "celebration of the NHS" instead of an anti-government protest! This is probably quite understandable, since as far as union leaders like Prentis of Unison is concerned, it was not appropriate even to hint at rocking the government's boat after the new Brown regime took over. Especially if a general election might be called - which was thought to be a possibility at the time. So Unison handed out hearts with "I love the NHS" on them. And hardly anyone came.

There is a way to resist

Since his appointment, Darzi has been involved in an on-going charm offensive in order to convince NHS staff, in particular, that the government's reforms should be allowed to go through. This is where the biggest stumbling block has been quite rightly identified. Because who, other than those who work on the front line, really knows the full impact of the government's privatisation and cost-saving policy? So he has opened blogs, e-mail discussion sessions and has put up questionnaires. And he can be watched and heard on "You tube".

A number of conferences and consultations have been held for and these will continue. Whether the majority NHS staff are going to be taken in by all of this is doubtful, however. But will the scepticism of NHS workers turn into anger which is expressed in real resistance? We can hope so. And there are real grounds for this hope, as one case in particular bears out. This is the case of Karen Reissman, a particularly dedicated community psychiatric nurse in Manchester, who was sacked on the 5 November for speaking out against the cuts in mental health services. She had twice been interviewed by national newspapers in 2006 about the mental health services and the deleterious effect of the transfer of work to the voluntary sector on patients. But the Trust which employs her decided to get rid of her "for bringing the Trust into disrepute".

The real reason may well be that Karen Reissman is also active in her union branch (of Unison) and this branch organised a successful strike in January 2007 against the cutting of 40 nursing and therapy jobs and pay downgrading.

When she was sacked, 150 mental health workers went on indefinite strike in her defence and have been supported by many of their patients in fact! The appeal against the sacking was lost early in December. After 6 weeks on strike the 150 workers have suspended their action. The official support of the Unison bureaucracy may well help Karen win an employment tribunal eventually. But it remains to be seen whether the "national campaign" it says it will launch will keep the fight against the Trust bosses alive.

Over the past 10 years nothing significant has come out of any of the official union campaigns - while drastic cuts and closures and losses of thousands of jobs have occurred. And as the 3 November fiasco "celebrating the NHS" shows, the union machineries are more likely to intervene to prevent any fight against the government than organise it.

Neither have the campaigns started outside of the unions had any real effect. But what the Karen Reissman case proves is that NHS workers are prepared to take real action if they judge it to be necessary, both against cuts and in solidarity with others. And they are absolutely right to do so!