This week we heard Jane Ellison, the public health minister, admit that the Coalition government has lost day-to-day control of the NHS. This supports the research conducted by the Labour party into the state of NHS finances that showed one in three trusts in financial deficit this year, compared to only one in 10 at the last general election. Of those, 64 per cent had entered the red in the last 12 months.
Much of the blame for this this perilous financial situation can be laid at the feet of Andrew Lansley’s much hated Health and Social Care Act 2012. However, simply repealing the act is not sufficient to restore the NHS to financial health. The Labour party must come out with strong policy to demonstrate how it would regain control of NHS finances.
Counter-intuitively, the most important thing is to leave the new NHS structures alone. The recent restructure was hugely costly, running into billions of pounds, but also hugely distracting and disruptive to staff when they are trying to care for patients or run a hospital. Having just been through an unnecessary, unwarranted and unpopular reorganisation, NHS staff desperately need a period of stability. So the question remains, without restructuring, how can the Labour party regain control?
Imagine if you are a new mother and your baby has a fever. You are not sure what to do, so contact your GP for an appointment. There are none available until later in the week. It gets worse through the night, so you contact the NHS 111 service and wait for a contracted private provider to come and see you. While waiting you become so concerned that you head to A&E where you know you can see a doctor straight away. This kind of story is typical across the country. Unplanned hospital care is expensive and preventing people attending A&E and being unnecessarily admitted to hospital is essential to get on top of hospital deficits. The key to this however lies in primary care. United Kingdom general practice is some of the best in the world, however GPs are overworked and underfunded, resulting in a desperate shortage of appointments and a lack of time for proper continuity of care. This is likely to worsen and many GP practices are expecting cuts of up to 17 per cent over the coming year. This needs urgent redress and the Labour party should make a commitment to increase the number of staff working in the community and free up more time for doctors, nurses and carers to spend with their patients.
GPs and practice managers need to be free to design integrated community services to meet the needs of the population they serve in collaboration with their local hospital, public health department and voluntary sector organisations. There are examples, like the Bromley-by-Bow centre in Tower Hamlets, that show how this can be done; the Bromley-by-Bow centre is a community centre based around a general practice that also incorporates a social enterprise, which provides a wide range of other wellbeing services to tackle some of the wider determinants of health, such as loneliness as unemployment. However, the restrictions caused by commissioning rules and competitive tendering have made this kind of practice more difficult. Most GPs simply do not have time.
Most of the hospitals in the worst financial difficulty are those with private finance initiative contracts. It is not disputed that there was a desperate need for new hospital facilities, however the contracts that were negotiated 10 years ago to fund them are causing huge problems to hospital finances today. The PFI payments continue to increase annually in line with the contractual agreements, while hospital budgets are being savagely cut. At Barts Health NHS Trust in east London PFI payments now consume £129 million per year, 15 per cent of the mega-trust’s budget. This inevitably leads to a reduction in services, staff cuts and a poorer quality of care. The Labour party must get on top of its PFI legacy and look into removing this dreadful burden from hospital finances.
A case in point is the debacle surrounding the deficit developed at South London Hospitals NHS Trust, which, suffering under an overwhelming PFI contract, caused the government to bring in ‘special administrators’ to improve the hospitals finances. However, the system must be broken when the proposed solution to dealing with a hospital in deficit is to close a neighbouring service to change where people go to access healthcare (and thus the funding that follows patient activity), as was the case when an administrator tried to close Lewisham Hospital’s A&E. The HSCA has enshrined a system where the provision of healthcare is ultimately determined by market forces. Health however is not a commodifiable product or service and reliance on finance alone to determine what health services are available for a population will inevitably see good hospitals begin to fail. Health services should be based on population need and value for money, not hospital deficits.
Thus, the first point of principle should be to reinstate the duty of the health secretary to ‘provide and secure’ a comprehensive NHS, rather than the weaker stipulation to ‘promote’ it, as amended by the HSCA. This places the responsibility for the NHS firmly back into the hands of the secretary of state and ultimately brings the power to determine back into the hands of the people through our democratically elected politicians. Not in the invisible hands of deficits, accountants and administrators.
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Tim Crocker-Buque is a doctor and public health specialist
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Photo: Chris Jones
This article is entirely admirable and the Labour Party ought to take careful note of what Dr Crocker-Buque is saying.
It is, of course, nonsense to say that the provision of healthcare should be dependent on what are artificially determined financial targets, rather than the medical needs of the population. The situation has arisen from increasingly advanced forms of treatment and longevity (plus overall managerial incompetence) clashing with governments wanting to spend less of GDP on health and social care, whereas the opposite ought to have been happening.
Spending more on health and social care, if properly presented, would be something I believe the public would accept, because the one thing they don’t want is payment per item. If the public, as a whole, wants a means-tested healthcare system, it implies that it wants the poor to die, which I can’t believe to be the case, even in a largely neo-liberalised Britain.
The wide adoption of PFI contracting by financially unsophisticated governments was Enron accounting writ large and we are now paying the price.
One can’t make this sort of comment without suggesting a remedy. What I think the Labour Party should do is to gather together a team of forensic accountants and bright legal people to examine very thoroughly all the PFI contracts to see whether they are valid in law. There may have been lots of misrepresentations, deceptions, guesstimates and so on perpetrated by private sector negotiators who took advantage of the negotiators for the public sector.
Predictions on the course of interest rates may now be proving wildly inaccurate and there may well be an equivalent, in PFI contracts, of the swaps scandal which some private businesses are now having to contend with.
The objective of this would be to unwind the PFI contracts and put the whole of the financing of the NHS into the hands of the Treasury where it properly belongs and should never have left.