This first appeared on the Huffington Post 05 July 2017
Dear Mr Hunt
The 69th anniversary today of the National Health Service is a timely but sad occasion on which to draw your attention to the end of the service in England as we have known it, a service for which you have been responsible for over the last five years – the 29th minister since 1948.
All 28 of your predecessors had a legal duty to provide key health services. The Health and Social Care Act 2012 abolished that duty, and has since given free rein to the external market, building on the internal market introduced in 1990, its development through what are now semi-private NHS Foundation Trusts and the scale-up of the Private Finance Initiative under the Blair government. The dismantling and fragmenting effects of the Act are now being felt in your so-called ‘Sustainability and Transformation Plans’, reported to require £22-26 billion cuts from health and social care costs in five years. These are proceeding in tandem with local government devolution deals made, according to the New Economics Foundation, “between elites behind closed doors, with minimal, and posthoc public participation“, at the same time as the local government finance system is being radically and regressively re-designed, which will increase inequalities.
You are ideologically committed to the market, and the enormous waste of money, lack of strategic planning, and exploitation of staff which implementing it involves may be difficult for you to accept. But you have a moral and political obligation to do so.
We know that the market costs more, as a result of unnecessary services, excessive administrative costs, fraud, denial of care, profits, and other problems – about 30% of health spending in the US in 2009. We know that the £8.7 billion you state was spent on private sector providers of secondary care in 2015/16 – an increase to 7.7% of total NHS expenditure – is a gross under-estimate of how much public NHS money goes to private companies, as it excludes primary care and community and mental health care, contracts between trusts and such companies, management consultants, and legal fees and private finance payments. We know that competing for contracts takes clinical staff away from providing treatment. We know that NHS problems will be further exacerbated by the planned return to PFI (codenamed Project Phoenix) coupled with the Naylor Report on the disposal and further sell of NHS land and buildings.
We know that the market results in dominant providers competing for patients and engaging in risk selection, while fragmenting services.
Cross-party support for lifting the public sector pay cap is welcome but it will not address the inefficiencies of the market or the lack of funding, nor will it help the many staff transferred out of the NHS under commercial contracts to the for-profit sector. Wages and terms and conditions of these staff are not routinely collected.
The 2012 Act marked the end of universality. Under your regressive plans to carve out and shift more health service functions to cash-strapped local authorities as part of the move to STPs, devolution, and so-called ‘integration’, the only recourse under current policy will be to cut and close NHS services, reduce entitlements, privatise care, and allow charging and sale of private health insurance – which is what the private sector is lobbying for.
Scotland and Wales, also underfunded by the Treasury, have abolished the internal market by removing the disruptive elements and made prescriptions free. Scotland has also made personal care free at point of delivery, allowing for integration of health and social care.
We call on you on to face up to the reality of the NHS in England that you have deliberately underfunded and prepared for cuts, closure and privatisation, and to support the NHS Reinstatement Bill.
Allyson Pollock and Peter Roderick
Co-authors of the NHS (Reinstatement) Bill
Pollock AM. How we could have a national health service in Ireland. The Irish Times 30 Sep 2016.
Filippon J, Giovanella L, Konder M, Pollock AM. ‘Liberalizing’ the English National Health Service: background and risks to healthcare entitlement. Cadernos de Saúde Pública. 2016;32(8). download
The Coalition Government abolished the public NHS in England when it passed the Health and Social Care Act in 2012. This Act didn’t directly affect the NHS in Wales, Scotland and Northern Ireland, but could have grave long-term consequences for the NHS in the devolved nations, including Scotland.
The Act effectively reduces the NHS to a funding stream and a logo. Behind the logo, corporations bid for health contracts in a regulated market. Privatisation of the NHS has hitherto been incremental as successive governments have passed legislation to promote privatisation. But this Act, described by Lord David Owen as the ‘secretary of state abdication bill’, removes the duty on the secretary of state for health to secure and provide comprehensive health care. So the rate of privatisation and closure of NHS services is accelerating across the country.
Since 2003, government policy in England has been to channel billions of pounds of scarce NHS funds to the for-profit private sector. For example the ‘independent sector treatment centre’ programmes diverted more than £5bn, and the government has recently announced that all GP services will go out to tender for private providers. The consequences of the market are felt every day as people see local services closing, and experience real reductions in access to diminished services – from struggling A&E departments to outsourced cancer care. Loss of NHS services mean people will have no choice but to go without or pay for health care through health insurance or out of their own pocket.
Handing the NHS to the market is a highly inefficient way of delivering health care, introducing new costs that are not experienced in public systems. There is mounting evidence that the English NHS is paying for work regardless of whether it is done or not: with one contract, Netcare did not perform nearly 40% of the work it had been contracted to do, receiving £35.1m for patients it never treated. The English NHS is on a track towards the US system, where commercialisation results in around $750 billion wasted each year due to overtreatment, undertreatment, and billing, invoicing, and marketing costs.
Aneuran Bevan, the founder of the NHS, said the NHS will last as long as there are folk left with the faith to fight for it. Here in England a number of health experts are working on a new Bill to restore and reinstate the NHS in England so that people will once again enjoy the same rights as are currently enjoyed by their relatives and friends in Wales and in Scotland. But the abolition of the NHS in England means decisions and control increasingly rest with commercial providers and the role of regulators is to keep the market operational, not to meet people’s needs or to ensure equity of access and access according to need.
If the English NHS is not restored, consequences for Scotland are serious. The NHS in Scotland may not be suffering these changes, but funding for the NHS in Scotland is allocated through the Barnett formula, so any reduction in NHS funds in England translates into reduced funding for Scotland.
The consensus that once bound the UK is breaking down due harsh policies enacted in England by the current government. Policy differences between Scotland and England are growing. Education, long term care and NHS are key examples of where Scotland takes a different direction on policy, but remains under the stranglehold of the Westminster Treasury. A Yes vote in the referendum would free Scotland from this stranglehold, and allow politicians in Scotland to control public finances as well as NHS policy.
But protecting the NHS is not just a question of funding; it is a question of political will and determination. People in Scotland must take more active steps to protect the Scottish NHS from international market predators and ensure that services delivered and provided are both effective and efficient. The Scottish NHS is not perfect and we must safeguard against the introduction of charges, especially if health and social care are merged and integrated. There are some things that should not be for sale in the market but should be available on the basis of need, and in the referendum Scots should make a decision that safeguards the principles of access and universality for health care and for education.
The vision of an NHS, which is there when you need it and free at the point of delivery, is part of our social contract. We, the people, own our NHS, and politicians have to be brought to account for the decisions they make. The NHS was formed as a result of the consensus that came about after two world wars, when so many gave their lives. But across the United Kingdom, our shared entitlements are now at risk and our NHS is based on different principles in different nations.
Promoting the principles of a public NHS will require creating new alliances across the regions and countries of the UK. Vested corporate interests are so keen on breaking up the welfare state and our entitlements and rights not just in the UK but across Europe. These interests need to be challenged by developing new economics. For international investors and US corporations the health systems of the countries UK are seen as the unopened oyster ready to be privatised and exploited – hence the controversial debates and opposition to TTIP – the Trans-Atlantic Trade and Investment Partnership between the USA and Europe that could make NHS privatisation irreversible.
Popular sovereignty and self-determination are the crucial route to upholding political principles. English governments have acquiesced to private interests. People in Scotland should uphold the principles of a public NHS when they vote in the referendum in September, and choose the way and means to defend our vital principles. At the present time, and in the absence of any reversal of neoliberal policies in England, the clearest way to defend and promote the principle of a public NHS is to vote for Scotland to have full powers and responsibilities of an independent country.