When the coalition government first introduced its landmark Health and Social Care Act in 2010, health secretary Andrew Lansley claimed the NHS would never again need to undergo such huge organisational change.
But even at the time, one widely respected commentator warned that – far from being the final fix that Lansley had advertised – the act “could become this government’s ‘poll tax’”.
In the event, it has been a slow-burn poll tax. Only now, ten years after it came into law, are we seeing its full effects, with publications from The Times to the Morning Star reporting that “A&E delays are ‘killing up to 500 people a week’”.
This figure – 5% above the normal number of people who die each week, though that baseline is also rising – can surely be traced back to the act, which ushered in a greater wave of privatisation than ever before. It compelled NHS management to behave as if they were in the private sector, competing to win business, and led to an increase in the proportion of contracts won and the use of contracts overall.
At the time, the damage caused was little noticed because government cuts in the first round of austerity targeted local authorities and adult social care. The first group of people to see their life expectancy fall were elderly women who most often lived on their own. It was in 2014 that this connection became apparent.
Back then, the government was still confident, with the Department for Health and Social Care rebutting any suggestion that austerity and privatisation might be linked to mortality. The privatisation figures were also opaque. In 2015, halfway through Jeremy Hunt’s tenure as health secretary, it was reported that ministers were misleading the public. By that point, private firms were winning 40% of new contracts – far higher than the 6% spend share claimed by the government and almost identical to the 41% won by NHS bodies.
The first great increase in mortality was recorded in that same year, a 5% rise that the government tried to attribute to influenza. The problem with that explanation was that the stalling and falls in life expectancy were not seen to the same extent anywhere else in Europe.
Last year it was claimed that austerity since 2010 had led to a third of a million excess deaths
As NHS waiting lists spiralled, a tenth of all adults, most of those who could, were resorting to accessing private health care in 2021. But, in doing so, they lengthened the lists further by jumping the queues and thus diverting resources.
By April 2022, the number of vacant beds in hospitals was at an all-time low. Estimates of the damage done kept rising. Less than six months later, it was claimed that austerity since 2010 had led to a third of a million excess deaths, twice as many as from the pandemic.
Now, A&E departments are stretched to capacity, unable to clear patients to other beds in our hospitals as they could in the past. Those other beds cannot be cleared as they were before because adult social care has been repeatedly decimated, with what is left being tendered out to private companies.
All of this was foretold. In the four years after 2015, the value of one group of private sector contracts in the NHS rose by 89%. These figures were released just before the 2019 general election, partly in response to Matt Hancock, then the health secretary, claiming that “there is no privatisation of the NHS on my watch.”
Again, the damage was not so much through the extent of covert privatisation, but through the wider ethos that had been promoted. Take the USA: most of the enormous amount of money spent on healthcare there has little impact on improving health, because the ethos is wrong.
OPINION: Sunak wants yet another round of cuts to public spending. And just like in 2010, we didn’t vote for it
It is sometimes said – wrongly, that is – that the NHS has not been further privatised because the share of its spending that went to the private sector remained roughly the same between 2012 and 2020. By 2020 that share was about 7%, or just under £10bn a year. It rose to over £12bn during the pandemic when the government paid private hospitals to treat patients, but because overall health spending rose, the proportion remained roughly the same, still around 7%.
But the number of private companies involved did increase greatly, particularly in areas where there was already more private healthcare. By last year, private firms were delivering a quarter of all planned NHS hospital treatment in the least deprived areas of England, and 11% in the most deprived areas. Those shares – which have risen since 2020 – are higher than the overall 7% because it is in planned hospital treatment where the private sector has most infiltrated the NHS.
Last year, the Health and Care Act of 2022 put paid to Lansley’s claim that he had fixed the NHS ‘once and for all’. The act reduces the compulsion of the NHS from having to tender so many services to private sector bidding in future, but it was not designed to stop the rot. It will not solve the service’s problems, though there is hope that it could be the beginning of an actual change in ethos.
The pandemic made the effects of privatisation clear: Britons now have the worst access to healthcare in Europe and some of the worst post-pandemic outcomes. But the successive health secretaries who inflicted this tragedy are unrepentant.
The pandemic made the effects of privatisation clear: Britons now have the worst access to healthcare in Europe and some of the worst post-pandemic outcomes. But the successive health secretaries who inflicted this tragedy are unrepentant.
If Jeremy Hunt succeeds in replacing Boris Johnson as British prime minister, it will be another instance of the ‘nice Tory’ coming after the panto villain.
Hunt’s pitch to the Tory faithful is that he’s the ‘serious’ one: the earnest ex-head boy with a grasp of detail and the ability to get things done. And that impression appears to hold water, with even the liberal media repeating these ideas.
Earlier this week, The Guardian’s Ben Quinn waxed lyrical about Hunt trying to play the role of “elder statesman from the backbenches, offering gentle and usually friendly criticism over the government’s Covid mistakes”. Of his latest leadership hopes, Quinn was positive: “Firmly on the centrist side of the party, he could be viewed as a calming presence after the tumult of the Johnson years, if the membership are desperate for some stability.”
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The fact that Hunt was health secretary – the longest-serving in history – barely makes it into the narrative at all. If it does, it’s restricted to his battles with junior doctors and funding – both of which Hunt likes to portray as victories.
Maybe it’s not surprising that so much of the media takes at face value Hunt’s self-presentation as a nice guy with a “consensual approach” (slogan: “Unite to win”). For most of his tenure as health secretary – except, perhaps, during the junior doctor dispute – they fairly uncritically adopted Hunt’s persona of the ‘champion of patient safety’.
I spent much of Hunt’s period as health secretary running openDemocracy’s OurNHS section, investigating what he was really up to. I soon discovered that when you looked past his press releases, you found a very different story – one of missed targets, lengthening waits, crumbling hospitals, missed opportunities, false solutions, funding boosts that vanished under scrutiny, and blaming everyone but himself. This is that story, which was first published on openDemocracy on 13 July 2019.
Hunt’s hospital legacy
Hunt took over responsibility for the NHS in 2012. By the time he left the post six years later, patient experience and staff morale had both taken a dramatic turn for the worse across many key indicators. Winter crises deepened, with official figures showing 2017, 2018 and 2019 were successively “worst on record”. The British Medical Association (BMA) reported that by 2018, “the “winter crisis” has truly been replaced by a year-round crisis”.
Nationally and locally, a range of treatments were restricted. Hernia, hip and knee operation patients weren’t treated until they were in severe pain. Cataract operations and hearing aids were restricted to one eye or ear (who needs two anyway?). Vasectomies, erectile dysfunction treatment and diabetes monitoring were scrapped or severely restricted in growing numbers of areas. In response, NHS hospitals increasingly turned to offering ‘self-pay’ options to private patients.
Hunt oversaw years of historically low funding increases (around 1%, compared with an average of 6% in the years between 1997 and 2010, and compared with the 4.3% recommended by the Office of Budget Responsibility and the likes of the Kings Fund, Health Foundation and Nuffield Trust, as the minimum to keep up with health inflation and increasing demand). Perhaps most damagingly, he oversaw a significant cut to the amount that hospitals were paid per procedure (payments which make up three quarters of their income).
Hunt’s response was to send out “failure is not an option” missives to hapless local NHS executives, instructing them (on pain of having their entire board suspended) to clear their financial shortfalls, while making sure they did so “without compromising patient care”. So that’s all right then! Even when “extra” money was found, as it was to some extent after the 2015 election, it came with so many strings attached that frontline patient care received little benefit, and was often in the form of loans that mean, remarkably, hospitals are now more ‘indebted’ to the government, than they are to the PFI deals that are still squeezing them. Hunt’s parting gift, the NHS ‘Brexit Dividend’ birthday present, is also full of strings and inadequacies, as we’ll see below.
Hunt’s reaction to this was to introduce what I dubbed a “Hospital Closure Clause” into an unrelated piece of legislation, which stripped away many of the requirements to consult local people on future closures. Further closures, land sell-offs and down-grades to services and opening hours have followed. And justifications that the land sold off by hospitals would be used to provide homes for nurses have proved utterly hollow when it turned out that only 17% of the houses built – fewer than 1000 homes – would be ‘affordable’. The trend is likely to continue, given that Hunt’s much trumpeted ‘NHS birthday present’ (of which more later) did not cover capital funding for buildings and equipment.
In 2019, the NHS had a £6bn backlog of essential maintenance and repairs, as under Hunt £4.3bn was raided from capital budgets to pay daily bills. And hospitals were told (by the Naylor review) that the way to make up this shortfall was to sell off more land and buildings, and enter into more private finance arrangements.
This policy failure, during a funding squeeze, is perhaps not surprising – the reality is that care at home requires more, not less, funding than care in hospitals, as reviews by the University of Manchester, the British Medical Journal, the National Audit Office and even the Department of Health itself have shown. Hunt repeatedly ignored the many experts warning him that this was the case. In the end, though, billions of pounds of ‘transformation’ money supposedly set aside to deliver the policy change, instead had to be quietly re-purposed into keeping cash-strapped hospitals just about afloat.
Meanwhile, in vital but neglected areas such as general practice, maternity and mental healthcare, Hunt routinely over-promised and under delivered.
In October 2017, Hunt told MPs: “We’ve got 30,000 more people working in mental health today than we had when [Labour] left office” – a claim that was revealed to be false. Not long before leaving office, he won headlines for promising that mothers would get a ‘dedicated midwife’ throughout pregnancy and birth, although later reports suggested that this wasn’t, in fact, the case, and that women were just being promised ‘one of a team’. In other words, no change.
Not long before his departure, Hunt told Parliament that NHS privatisation “is not happening” and was “fake news”. But his actions suggest he was as ideologically wedded to continued competition and privatisation (in various guises) as his notoriously destructive predecessor, Andrew Lansley. An enormous amount of clinical and management energy was wasted in having to work to keep services from being chipped off by the private sector – even though such privatisation is a hugely costly process with no proven benefits.
While various privatisations collapsed, failure seemed to be rewarded. In 2013, a privatised treatment facility in Stevenage run by the company Clinicenta was bought back by the NHS following the deaths of three patients during routine surgery, with local officials raising concerns about “serious failings” and “evidently substandard” care. But just as Clinicenta was collapsing, its parent company – Carillion – was rewarded with further NHS contracts including major PFI schemes at Royal Liverpool Hospital and Midland Metropolitan Hospital.
After Carillion itself collapsed, The Guardian revealed documents that showed that, “civil servants working for Jeremy Hunt successfully lobbied the Cabinet Office to stop failing Carillion hospital projects from being overseen by an independent watchdog”.
The tech bonanza is another novel form of privatisation. Hunt’s successor Matt Hancock has been criticised for an overly credulous attitude to technology, but Hunt laid all the groundwork. The NHS signed substantial contracts with the likes of health app firm Babylon under his oversight, as well as running into a massive controversy over the care.data project in which Hunt and his tech Tsar, Tim Kelsey, were unable to adequately reassure a concerned public that personal data would not be sold to private firms. In what he described as his “most important speech as health secretary”, Hunt boasted that; “The future is here… 40,000 health apps now on iTunes… this is Patient Power 2.0.” The announcement was somewhat overlooked as it was also the speech in which he launched his astonishing attack on doctors (more below). But perhaps Hunt envisaged a future with fewer doctors – not long afterwards, he faced fierce criticism by doctors for issuing “potentially fatal” advice to parents to use “Doctor Google” to diagnose their children’s rashes.
David Cameron sold the controversial 2012 Health and Social Care Act by claiming that it put doctors in charge of decision-making. In reality it put privatisers in that position, along with commercial providers taking over and sub-contracting to the NHS. In 2016, openDemocracy reported on a version of these arrangements called “Accountable Care Organisations”, an idea based on US hybrid insurer-hospital organisations such as Kaiser Permanente. This gives private providers involvement in decision-making about what treatments patients do or don’t receive, and financial incentives to minimise treatment (as Michael Moore’s film ‘Sicko’ exposes). Hunt visited the US firm at least three times.
However, Hunt did little to promote the real solution – reintegrating social care under the NHS’s public, free provision. Instead, he suggested that the ageing population was a massive “commercial opportunity” – and ‘integration’ began to look to campaigners like merely code for ‘helping the private care sector get its hands on more NHS cash’.
The underlying issues were left unresolved, the promised social care green paper was delayed no less than five times (and counting), experiments to ‘integrate’ ran into frequent problems, and the social care sector continued being just another convenient scapegoat for delays in discharging people from hospital. Hunt is still pursuing market solutions, suggesting during the leadership campaign that while social care cuts had gone too far, the answer is to ‘incentivise’ individuals to save for their own social care.
Perhaps none of this is surprising. Back in 2005, Hunt co-authored a book called ‘Direct Democracy’, which stated; “Our ambition should be to break down the barriers between private and public provision, in effect denationalising the provision of healthcare in Britain” and that the NHS was “no longer relevant in the 21st century”, although he has since distanced himself from the book’s vision.
Hunt adopted three key strategies to ensure that the NHS wasn’t his career graveyard, as it had been for many Tory predecessors: hiding, hiding, hiding the figures, and (most of all) hiding behind someone else. His biggest talent is also, in fact, Boris Johnson’s: ducking accountability. The strategies are somewhat different, of course. Johnson’s bluster makes you suspect you’ve been had (but it appears that Britain, or at least the Tory part of it, includes a lot of masochists who rather enjoy that). Hunt’s smoothness means you don’t even notice. And the success of these tactics tells us much about technocratic attitudes to democracy, accountability, leadership and so-called public service ‘reform’.
Hunt’s complaints about Johnson refusing to debate him rang hollow to those of us who have followed him closely. Hunt is famous for dodging debates, whether with junior doctors, angry hospital users, in parliament or on the ‘Today’ programme, on which Hunt was a regular no-show during NHS crises. Where he did appear, he often restricted his appearances to issues over which he had no actual control, such as promoting a sugar tax. In fact, he became so notorious for shirking debate that hospital campaigners launched a “Hunt the Hunt” campaign, and junior doctors camped out on his departmental doorstep.
Blaming the patients
Hunt had no end of people that he (and his media cheerleaders) could blame for the problems besetting the NHS.
First off, patients. Be they old people, for being too old (“a challenge more serious than global warming”, Hunt said, even though this narrative doesn’t actually reflect the reality that health needs are highest in your last years of life, whenever that comes). It is true that health needs are rising among the poorest – and health inequalities increasing sharply – but blaming austerity policies and inequality for rising health demand wouldn’t have endeared Hunt to anyone in the Tory party. Instead, he relied on the ‘ageing population’ line routinely, when pressed on failures to meet NHS targets – such as an interview with the BBC’s Laura Kuenssberg, where he said, “the targets you talked about are because of the pressures of an ageing population”.
To add insult to injury, under Hunt’s tenure, the dehumanising labelling of old people as “bed blockers” returned, even as he did nothing serious to solve the issues of social care. Then there were children – and parents – blamed for being too fat, even as public health funding to address such issues was slashed. And smokers, who, along with overweight people, started to be banned from routine surgery under Hunt’s watch. Such patient-blaming decimated the NHS’s core values of universalism and comprehensive care, to the horror of doctors and nurses.
I asked Hunt about this at an Institute for Government event not long before he left office. He told me blandly that, “this shouldn’t be happening”. But there was no sign of him taking any action to stop what he routinely blamed on ‘local decisions’ (as we’ll see again with rationing of care).
Always top of the scapegoat list, of course, are migrants. From 2013 onwards, Hunt’s department worked closely with the Home Office on a string of initiatives to impose the ‘hostile environment’ (a policy which the former head of the NHS described as a “national scandal”). That led to cases like Albert Thompson, the Windrush victim who was denied cancer care. Hunt went pretty unscathed when these scandals finally broke through into the public consciousness, and these restrictions are still largely in place – along with the upfront charging systems now set up in hospitals, which many have observed could now easily be rolled out to others.
Blaming the staff
Blaming the staff is, of course, another favoured tactic of politicians, and one that Hunt embraced wholeheartedly (though he would no doubt like to think of it as ‘delegation’).
In terms of senior staff, in 2013, Hunt hired his Oxford contemporary, Simon Stevens, as chief executive of the NHS. Stevens quickly adopted the role of media frontman whenever the going got tough.
In hiding behind Stevens, Hunt benefitted from the post-2012 legal framing of the NHS as a standalone organisation (or rather, a tangle of competing, squabbling standalone organisations), given its money and left to get on with it. When problems arose, it was down to ‘the NHS’s own plan’, and ‘local decisions’. No longer did the secretary of state have a duty to provide or secure healthcare for us all.
But on the whole, Hunt outsourced strategic policy thinking (and ‘heavy lifting’ to shift public attitudes on charging, privatisation and hospital closures) to costly and wasteful management consultants including the Big Four accountancy firms (despite promising to rein in this spending), not to mention a collection of sirs, lords and commissions, regulators, right-wing think tanks, and in-house consultants dubbed “ninja privatisers” who were responsible for numerous expensive failures. (To be fair to Hunt, quite a bit of this policy outsourcing strategy was developed by his health secretary predecessors, both Tory and Labour).
As a result of the 2012 Act, Hunt had just one last bit of legal and parliamentary accountability for the NHS – the “mandate”, which required him to put the NHS’s annual objectives before parliament. But in 2015, when the scope of the mandate was being revised for the next five years, his department issued a public consultation that Hunt somehow failed to actually tell anyone about (it wasn’t even published on their departmental consultation page) – a ruse that caused something of a backlash after OurNHS got wind of it, particularly given the hints about widespread withdrawal of treatment.
Frontline staff became Hunt’s favourite whipping boy
While senior staff and outsourced policymakers were convenient stooges, frontline staff became Hunt’s favourite whipping boy. He kicked off his tenure by telling parliament that “cruelty became normal in our NHS and no one noticed”, implying that the criticisms of the terrible Mid-Staffs scandal were normal for the million plus NHS workers.
But all this was just a foretaste of what was to come for doctors, nurses and other health workers.
In 2015, Hunt and Cameron promised a “seven-day NHS”, but Hunt was condemned in May 2016 by parliament’s Public Accounts Committee, which deemed the plan “completely uncosted” and said that Hunt’s department had made “no coherent attempt” to address the staffing impact of this pledge.
Hunt veered close to accusing anyone standing in his way of being responsible for “avoidable deaths”
Perhaps what aggravated and demoralised doctors and nurses more than anything else, was Hunt’s audacious use of tactical shroud-waving. Previous Tory health ministers frequently accused their opponents of using deaths to make political points. But Hunt repurposed this trick against his opponents, veering close to accusing anyone standing in his way of being responsible for “avoidable deaths”.
Announcing his intention to impose a new contract on doctors, Hunt claimed that “around 6,000 people lose their lives every year because we do not have a proper seven-day service in hospitals… No one could possibly say that this was a system built around the needs of patients – and yet when I pointed this out to the BMA they told me to ‘get real.’ I simply say to the doctors’ union that I can give them 6,000 reasons why they, not I, need to ‘get real’.”
Margaret McCartney, a GP, author and broadcaster, told me: “It’s dangerous to keep on misrepresenting data even when experts have told you that you are making a mistake… Hunt’s claim about weekend deaths, used to justify changes to the junior doctor contracts, has been debunked (patients admitted at the weekend tend to be sicker).”
The shroud-waving was a tactic he had already deployed effectively against his first parliamentary opponent, Andy Burnham, and indeed against interviewers. Questions about failures to meet targets on waiting times, when not being excused by the “ageing population”, were often met with impassioned statements about patients failed by the NHS in Mid Staffs, Morecombe Bay, Gosport and elsewhere – a strategy he also deployed consistently in media interviews (such as his interview with the BBC’s Laura Kuenssberg, when he was challenged on LBC by an angry doctor in the same week).
He had deployed the tactic too, against Lewisham campaigners, when his administrator’s report suggested closing the hospital and related changes would “save around 100 lives a year”.
Indeed Hunt has made the “patients’ champion” persona his own. He told the New Statesman that he had made patient safety his “life’s mission” and that when he left frontline politics; “I want to write a book on patient safety. I would like to do for patient safety what Al Gore has done for climate change…”
In reality, having wielded the Francis report into the Mid Staffs scandal as a weapon from the get-go, he junked most of its key recommendations.
Having promised in 2013 to bring in minimum standards of safety for ratios of nurses to patients, two years later he and Simon Stevens quietly tore these promises up as too “mechanistic”, to the concern of the report’s author, Robert Francis. Hunt’s repeated promise to put the patient at the centre of everything that the NHS did, including in its constitution (another Francis report recommendation) was similarly junked a year after its headline-garnering work was done. Promises to protect whistleblowers resulted in just another toothless system. Moves towards openness were undermined by increased reliance on the market and private sector provision, with nothing done to address the destructive ethos of competition between and even within hospitals that Francis had identified as a key part of the problem at Mid Staffs.
Phil Hammond, the doctor and broadcaster who has written extensively on patient safety, told me: “Hunt developed a selective interest in some aspects of patient safety… so although he will be able to cherry-pick to make it look as if some aspects of safety got better…. Hunt repeatedly refused to introduce mandatory safe staffing levels… There are of course some brilliant NHS staff who are very dedicated to safety, who have improved the situation in their particular hospital or GP practice, but I don’t really see how Hunt can take credit for that. Finally, despite his strong words about no more cover-ups in the NHS and better support for NHS whistleblowers, many of them say the situation hasn’t improved and they are still not being listened to and are being persecuted.”
So much for Hunt’s “patients’ champion” persona.
And of course, much else that happened to the NHS under his watch wasn’t very good for patients, either – in terms of safety, but also access to healthcare, privatisation and rationing. And this is where the last of his strategies came in very useful.
Playing with the figures
Part of Hunt’s pitch is that he is “on top of the detail”. In reality, he has worked to make it harder or impossible for the rest of us to check-up on the detail. Once A&E waiting targets were routinely being missed, he simply stopped publishing weekly data on the failures and dropped hints that the target would soon be dropped. Similarly, in response to regularly missing the target on maximum 18-week waiting times for planned operations, that target was quietly dropped. In response to alarming headlines regarding the rising number of hospitals declaring ‘black alert’ (unable to guarantee life-saving emergency care, and having to divert patients elsewhere), the ‘solution’ was to ban hospitals from using the term ‘black alert’.
Under Hunt, the Department of Health routinely refused to answer parliamentary questions and Freedom of Information requests about which private companies the NHS’s money was going to on the basis that they didn’t centrally collate it. And it was also reluctant to release raw, uncollated spending data, being the last department to do so and only giving in after a petition to release it. Inconveniently timed information on the financial crisis engulfing hospitals was tucked away from view too.
Also worrying, it turns out (in the long term plan) that Hunt’s deal was conditional on the NHS achieving significant savings through the use of technology (something that many experts were dubious about), reducing face-to-face appointments by one third, and also on there being no additional pressures from the social care sector (that was on the verge on collapsing). And this 3.4% doesn’t apply to capital expenditure, staff training and pay, or public health budgets – all of which would remain up in the air until the next spending review. Theresa May promised the “Brexit dividend” would fund the increases. That didn’t quite pan out though, did it? As a Nuffield Trust health expert put it, “The NHS would be wise to hang onto the receipt for this particular birthday present.”
There are many more facts I could throw at you to help you see Hunt’s legacy. Public satisfaction with the NHS fell during Hunt’s time in office, for example. Both maternal deaths at childbirth and infant mortality started to worsen again towards the end of Hunt’s tenure, after decades of improvement. And one last statistic is perhaps the most damning. In an interview with the New Statesman, he quoted Stephen Pinker as saying that “life expectancy has gone up!”. While this is true globally, the story in Britain is different. Since 2015, projections for life expectancy in the UK have fallen by more than a year.
It tells you much about British politics that a man with Hunt’s record was promoted to foreign secretary, and after losing one leadership bid, again now stands a small chance of becoming prime minister. It tells us a huge amount about the state of the British press that Hunt is treated as a serious candidate.
And it’s worth remembering, that whoever succeeds Johnson will face the same advantages that Hunt has always had: an establishment that doesn’t care too much what happens to ordinary people’s services, so long as no one makes a fuss, and a pliant media, always ready to believe the spin of some old public schoolboy.
The experts turn the nostrums of market efficiency which the free-marketeers have inculcated us with over the last 30+ years, on their head, writing:
“Privatised services cost the NHS and taxpayer far more than when provided by our publicly owned and publicly run NHS. That is because public health systems don’t seek profits. They don’t need to pay dividends to shareholders. They don’t have the added costs of private sector loans. And they don’t have privatisation’s heavy and unnecessary marketising costs of contracts, billings and all the extra administration involved.
The huge commercial costs and chaos caused by the ongoing NHS fragmentation are the direct result of privatisation. This is endangering the quality and safety of our public healthcare. That is why we need the National Health Service bill.”
And – noting how so much is being sneakily privatised under the NHS logo, they add:
“NHS services and assets, including blood supplies, nurses, scanning and diagnosticservices, ambulances, care homes, hospital beds and buildings – which the British public own – are being handed over to UK and foreign private companies. This is being done without a public mandate.”
I only really got hold of this when I had an MRI scan last September. From quizzing the radiographer, my GP and scanner suppliers and researching the purchase, manning and maintenance costs it seemed clear that my scan – provided by a private company – cost the NHS at least 25% more than if it had been provided by a nationalised NHS.
The inflated costs are everywhere – from PFI (£1bn a year) to profits made by private providers, to the vast costs of running the NHS as a ‘market’ (in fact, as a privatisers’ bureaucracy) – costs that are fiercely denied by pro-market advocates and carefully obscured by government – and independently estimated to waste anywhere between £4.5bn and £10bn a year – or more.
The economic case for renationalising the NHS and restoring it as a publicly owned and run entity seems unarguable. It should be the Labour Party’s trump card.
So why is the Corbyn leadership being so slow to grasp this gift horse? Why hasn’t it yet publicly embraced the NHS Bill which clearly sets out its intent to strip away the expensive market bureaucracy the NHS can ill afford?
Is Corbyn being “got at” as a well-placed observer suggested at the NHS Bill group meeting I attended a few days ago? Is his party running scared of fuelling the Greens, whose solo MP Caroline Lucas has been the tabler of the NHS Bill in Parliament and of whose renationalisation-studded Election manifesto the President of the RMT Peter Pinkney barked last March “If that isn’t bloody Socialism I don’t know what is!”
Or is the mantra of electability and the City-honed Damocles sword of Labour’s economic ‘incompetence’, which the Mandelson camp followers have held to the party’s throat for so long, still keeping even its newbie lefty(ish) leadership kneeling in an NHS policy desert?
A member of my West London 38 Degrees group, a lifelong Tory now lapsed, has no such hesitation. She supports the Bill and doesn’t mince her words in her letter to our local Tory MP; “We are not idiots; this government is pushing the country into private hands in every direction – and you only got 24% of the vote. I doubt any of you will get another term in office and the opposition parties are not any better.”
Signing herself “a sad, disillusioned resident of Fulham and ex-believer in the Conservative Party” she’s a powerful example of the simmering rage at the privateers’ long unfettering. “All they think of is money. What’s more important? Being aware of other people or just making money?” she asked me rhetorically.
This quiet rage at the corrupting monetisation of our political and civil institutions runs deep and wide and courses across party lines. And it’s up for grabs by a Labour Party prepared to stick its neck over the parapet and see a landscape budding with potential and surprising allies.
Suddenly this weekend there are straws of hope in the wind for NHS campaigners. The Socialist Health Association (SHA), like ex-Shadow Health Minister Andy Burnham, have been purveyors of the Blair/Mandelson City-sugared line on the NHS, which would leave it vulnerable to continuing privatisation under international trade and competition agreements. Accordingly they (the SHA) have been long-time opponents of the Bill.
But on Saturday their AGM voted by 30-1 to strongly back the Bill and do everything they could to encourage Labour MPs to back it. Does this signify a ‘left turn’ within the SHA? And – given some of its senior figures are rumoured to be amongst Heidi Alexander’s close advisors – what might all this portend for her future positioning on the NHS?
More importantly Shadow Chancellor John McDonnell has publicly re-confirmed his support for the Bill. The Shadow Health team have agreed to attend its Second Reading and debate next Friday 11th. Campaigners understand that there have now been discussions between Jeremy Corbyn, Heidi Alexander and Caroline Lucas.
Filming Joanna Adams in Darlington two days ago for the continuing saga of my documentary series Groundswell about her and the 999 Call For The NHS campaigners, I asked this organisation’s founder what she made of the Labour Party’s post-Corbyn shapeshifting. An acute campaigner, Joanna senses a sliding of the sands from under the Blairite sword-wielders of old and their followers.
But for now she’s staying with the Greens. If Labour can’t win back grassroots supporters like her from Labour’s old heartlands then its future as a party with a working majority seems bleak. It is in danger of being outgrown by the ‘new’ politics of internet-savvy, issue-driven grassroots. For them the 2008 crash and bank bailouts were a game changer – exposing not only the dirty secrets of the privateers and bankers, but the how whole the Blair project depended on the rigged, debt-inflated airbagging of Western economies which has been the developed world’s economic cornerstone since the late 1960’s and has now been punctured.
The NHS Bill is a game-changer, too, for the Labour Party. As its co-author Peter Roderick has said, it’s a gauntlet thrown down to the party and its moribund inheritance. Friday’s Day Of Action is an early staging post in the long struggle ahead to save the NHS from the bankers and privateers.
It’s a significant moment for the party that brought the NHS into being and an opportunity for it to further the necessary reconnection with its origins that the Corbyn ‘phenomenon’ has signalled.
How you can help: We’re asking everyone to ask their MP to attend the debate on Friday (details on the NHS Bill website) and, if you can, to come to the rally outside parliament from 11am on Friday, details here, and/or earlier outside the Department of Health at 9.45am, details here.
A fuller Q&A can be downloaded here, and leaflets to distribute in advance or on the day, clearly spelling out what’s at stake, can be downloaded here. This article is published under a Creative Commons Attribution-NonCommercial 4.0 International licence. source
The junior doctor contract governs the pay and conditions of work from doctors’ foundation year to registrar level. All doctors who are not consultants or fully qualified GPs are considered ‘junior’ doctors. This contract was scheduled for renegotiation, but the British Medical Association (BMA) – the largest representative body of doctors – walked away because the offer on the table was not fair to doctors and not safe for patients.
The government’s initial response was brazen, and threatened to impose the new terms without consultation – a position it has had to water down since the BMA decided to ballot its members for strike action. Here’s why the BMA has done so the first time in 40 years:
An NHS in crisis: overworked and undervalued.
Britain’s doctors have had enough. In a stretched and underfunded health system which doesn’t train enough doctors and nurses to meet its own needs – or invest in the infrastructure needed for new hospitals and facilities unless aprivate contractor is taking a nice slice of the pie – the solution seems to have been ‘work harder and take up the slack’. According to the Royal College of Physicians, the NHS “remains reliant on doctors working longer than their contracted hours…the amount of ‘goodwill work’ is increasing year-on-year.”
Trusts struggling to pay their tithes to the private owners of NHS hospital buildings have responded by reducing staff salaries, meaning fewer doctors and nurses are covering more patients and expected to do so for free. The situation has reached crisis point and doctors are experiencing enormous burnout, with more doctors applying to live abroad every year. Into this context came the new contract.
It’s not about the money.
The ‘offer’ of the new contract has been condemned first and foremost as fundamentally unsafe. Just as with the recent tube strike, the new contract threatens to force doctors to work longer and later with fewer safeguards.
The BMA approached negotiations acknowledging financial limitations but determined to improve safety: it wanted no doctor to work more than 72 hours in a week; no more than four nights in a week on-call; a rest day either side of nights before starting back on day shifts; and facilities to sleep-in for those who otherwise make a dangerous long drive home.
The government was unwilling to accept these terms, and furthermore wanted to reduce breaks to just one 30 minute break in a ten hour on-call shift. As a recent viral video asked, could you save a life if you’d been up all night?
But it is, also, about the money.
The new contract would mean a 15-40% pay-cut depending on your specialism, with GPs and emergency care doctors being some of the hardest hit. Let that sink in.
With wages starting beneath the national median anddecreasing yearly like all public sector pay, and out of pocket expenditure for licensing, exams and indemnities, junior doctors earn significantly less than the tabloids would have you believe. Their reports often use a cunning sleight of hand: taking the figures for the pay of those doctors doing the most private work – GPs who run a private practice and some consultants who run private clinics – and presenting the data as proof of ‘greedy’ public sector workers.
There are two ways doctors’ starting wages increase: extra pay for unsociable hours, and pay advancement as you progress through the ranks of seniority and responsibility. Both of these are under threat in the new contract.
The government has suggested that working from 7am until 10pm Monday to Saturday are sociable hours – and therefore should not be paid extra – which is funny considering MPs just reduced their own working hours and increased their own pay. As for pay progression with seniority, no actual offer was made.
The changes hit women hardest.
The contract changes penalise those who take time out to start a family and those who work part-time –overwhelmingly affecting women in both cases. Additionally there are concerns that changes to breaks will make work more dangerous for pregnant women. As noted above GPs will be amongst those taking the largest wage cut, one of the few specialisms with more women than men.
Hunt and the government have shown a complete disdain for even the barest semblance of actual negotiation. When the BMA walked away from negotiations a year ago, it wasn’t as a strategy to get better terms, it was because the negotiations were a farce. It has taken the threat of industrial action for a pathetic attempt at reconciliation to come from the Department of Health, full of vague, unconvincing rhetoric. It is too little, too late. No fruitful discussions can continue with Hunt as health secretary. We have no reason to believe in his word or his competence.
We deserve more. Doctors do not take strike action lightly. Whilst we will always maintain emergency and essential services, the BMA will be balloting its members to strike against the contract in the next month. We hope to see you on the picket lines.
About the author: Nick is a junior doctor. He tweets at @ZastaNick.This article is published under a Creative Commons Attribution-NonCommercial 4.0 International licence.
England’s Junior doctors held a 24-hour strike from 8am yesterday. It was the first of a planned series of strikes. Jeremy Corbyn’s Labour Party and the Green Party should be commended for their support of the strike. (The strike only applies to England).
While it’s very tempting to address the strike, today’s featured article instead addresses a fundamental problem with the NHS which is largely ignored by corporate media – that of the huge bureaucratic overhead of imposing a fake, imaginary ‘market’ so that the private sector can extort it’s ‘tax’. The conclusions to be drawn from this article should be clear.
But there is one pot of money that sits curiously unexamined, glistening and untouched.
It’s the cost of the NHS ‘market’ itself. Administering the hugely expensive artificial ‘marketplace’ created by successive governments to allow both NHS and private ‘providers’ to compete with each other to offer services to NHS and other ‘purchasers’.
No-one knows the exact cost of this bureaucratic ‘marketplace’. A recent estimate by rebel Lib Dems put the figure as high as £30billion a year. Dr Jacky Davis and other doctors and campaigners including the National Health Action Party have put it at £10billion a year. The Centre of Health & the Public Interest put it at a ‘conservative’ £4.5billion a year.
Even the most conservative of these estimates is a yearly amount which would, if re-directed away from useless market activities, fund both the £2billion annual NHS shortfalland free critical social care to everyone, which the Kings Fund’s Barker Commission recently said would cost ‘substantially less’ than £3billion a year.
Despite fierce urging from expert MPs to look at what the ‘market’ costs the NHS more closely, the government, mainstream media, think tanks and policy makers have dismissed, ignored and even suppressed this information, with unevidenced assertions that ‘modern healthcare systems’ need vastly expensive bureaucracy, market or no market.
Successive governments wedded to ‘market reform’ have refused to produce useful figures that would definitively establish the cost of the NHS market. It has been left to academics, MPs and activists to try and fill the void, through historical and international comparisons, as well as tentative attempts to cost different activities that are forced on the NHS by the ‘market’.
The Select Committee noted that the NHS would have some administration expenses even if it didn’t run itself as a ‘market’. But they noted evidence from the NHS Chief Historian, Professor Charles Webster that in the pre-market late-80s, the NHS spent only 5% of its budget on administration.
The difference in administration costs pre- and post-market – 9% of the NHS budget – is over £10billion a year of the current £120bn budget. That’s more than the entire cost of every GP in the land.
The government tried to suppress the 14% figure, which was in a York University report it commissioned then refused to publish for 5 years. The York study found that ‘market’ mechanisms like “the purchaser-provider split, private finance, national tariffs…mean…transactions costs of providing care have increased, and may continue to increase.”
The Select Committee report suggested that “the purchaser / provider split may need to be abolished”. They added that they were “appalled” that the Department of Health “was unable to give us accurate figures for staffing levels and costs dedicated to commissioning and billing.”
MPs concluded “the suspicion must remain that the Department of Health does not want the full story to be revealed.”
£10billion a year may be a conservative estimate
In fact the increase in administration costs due to the ‘market’ is likely to be even higher than £10bn.
Professor Colin Leys, author of ‘The Plot Against the NHS’, told OurNHS that these figures relate to 2003, before the second big wave of market ‘reforms’ including “the Independent Sector Treatment programme, the huge expansion of the Commercial Directorate of the Department of Health, the marketing division set up to help trusts learn to advertise and sell their services, the Competition and Cooperation panel, Monitor’s vast expansion…”
The key driver of high NHS inflation is rising drug and medical device costs, new, expensive clinical possibilities, and rising demand as the population ages, runs the accepted wisdom. So why have administration costs kept pace with – or even outstripped – these unavoidable inflationary drivers? Shouldn’t we expect to see administration costs forming a falling proportion of NHS costs?
Professor Webster told OurNHS that instead, “serial reorganisations and escalating marketisation are imposing enormous cost and waste on the NHS, with administrative costs spiralling out of control since 1980.”
Professor Leys adds, “It of course depends on how much you think admin costs would have risen anyway to deal with more complex interactions of modern health care, but to my mind attributing 20% of all NHS costs to admin costs [ie about £25billion], and half of that to the costs of operating as a market, is very reasonable.”
Professor Paton takes a more conservative view, halving the £10billion figure to conclude that “the recurrent annual costs of the market can be estimated (conservatively) at £4.5 billion”.
He concludes in his report earlier this year that the NHS market itself is “an unaffordable ideological luxury”, with few if any discernible benefits.
The market and ‘transaction costs’
Away from the academic estimates, though, a quick glimpse at the empty hospital carpark after the managers and admin staff have left for the day, brings home the reality of how much must be being spent on paperwork and IT white elephants to administer the market.
The market introduces ‘transaction costs’ – advertising, negotiating, contracting, invoicing, billing, auditing, monitoring contracts, collecting information, resolving disputes both in courts and out, all employing and training a ballooning bureaucracy – even leaving aside any profits extracted by the private sector.
At the grassroots, Hackney GP Jonathan Tomlinson told OurNHS that applying the ‘market’ adds huge costs at every stage, “because they diffuse through every interaction, from a decision to prescribe or perform a scan, make a referral, set up a service or close a hospital.”
Then there’s what Paton calls the “circular re-organisation”, with endless “re-invention of expensive agencies under different names supposedly abolished, alongside the costly complexity of the new, often overlapping, agencies …”
How many managers does it take to change a health system?
Then there’s the 211 Clinical commissioning Groups, advised by soon-to-be privatised Commissioning Support Units and NHS England (the biggest quango in history). All of them shove a lot of cash at the management consultants, too (under central quango instructions).
Then there’s the ballooning bureaucracy created to regulate and further marketise this decentralised jumble – the NHS Trust Development Authority, Monitor, the Care Quality Commission, NHS Professionals, NHS Property Services, Healthcare UK… Some of these bodies are soon to be privatised themselves – but, just like the rest of the ‘shadow state’ of management consultants and thinktanks, they’ll still be receiving huge chunks of public money.
Of course the NHS needs managers – but this many? Duplicated across so many fragmented, competing, deficit-ridden organisations?
There have been recent tentative attempts to cost some of the individual elements of the market. Just the legal fees to comply with one Clause of the Health & Social Care Act cost local Clinical Commissioning Groups £77million a year, Labour uncovered earlier this year.
And hospital cash is sucked up in fending off the private sector, too. Earlier this year, the competition to run just one hospital – George Eliot – cost at least one and a half million pounds of public money, my Freedom of Information requests revealed. Over half, £771,000, went straight into the pockets of the big 4 management consultancy firms. Such sums are not atypical – nor is the fact this process changed absolutely nothing, in the end.
Another million pounds has just been blown on tendering ‘older people’s services’ in the East of England – again for the private sector to try (and fail) to demonstrate they could do a better job. But the private sector has got deep pockets – and will keep trying.
There are tens of thousands more of these expensive tenders underway or in the pipeline in every part of the NHS. Dr Tomlinson says “we had to cough up £40k to tender for a local practice that we were already successfully running – and at least that to tender for the Out of Hours contract.”
International comparisons are also helpful. A recent Commonwealth Fund reports suggest that the – til recently – less marketised UK system has been the most cost efficient in the developed world. A still more recent report found that Scotland now spends substantially less on hospital administration, than does England’s increasingly marketised system.
The Liberal Democrat conference this week heard a minority report from the NHS working group which suggested that scrapping the NHS market could save as much as 25% of the annual NHS budget. But their proposals to scrap the market were denied a vote by the party leadership.
The report noted that “countries where there is market competition in healthcare spend between 20% and 40% of their healthcare expenditure on administration”. It highlighted evidence from international experts that the increased use of markets in healthcare sharply increased administrative costs in New Zealand. Canada, Australia and Germany – soaring in the latter case by 63.3% between 1992 and 2003 and now standing at 20% of their health systems costs.
In the most marketised system of all, the USA, one healthcare dollar in every three is spent on adminstration of a system that delivers far poorer outcomes than the NHS. The Lib Dem report points out that healthcare billing alone cost up to 13%, noting “billing costs in healthcare providers are ten times the average of all businesses in the US. There is an inherent complexity to the business of delivering healthcare.”
These arguments are frequently dismissed by opponents. Former Editor of NHS managers bible the Health Services Journal, Richard Vize dismissed Labour’s tentative efforts to cost the market as “The old line that culling bureaucrats and lawyers is all that’s needed to fund new services…does not stand up to scrutiny.”
But where is that scrutiny?
The government told the Health Select Committee that the NHS still had “consistently low management and administration costs, ranging from 3-8%.”. But MPs on the Select Committee found “considerable lack of clarity and consistency in … these data.”
Professor Webster (former NHS Chief Historian and Fellow of All Souls) says the “the managerial lobby” have mounted “a clever distraction…a defensive response…artfully disguis(ing) the scale of the increase by accounting procedures, such as concentrating on Managers and Senior Managers, to the exclusion of other relevant staff categories, reducing ‘administrative’ costs back to 5 or even 3 per cent.” But even this, he adds, cannot disguise that “the percentage of admin and clerical staff in the NHS has doubled (from 12%) since 1980”.
The government now boasts of ‘cutting red tape’, saying “There are now over 20,500 fewer managers, senior managers and admin staff, and nearly 14,500 more professionally qualified clinicians than there were in 2010.”
But as Dr Tomlinson says, any reduction in admin staff doesn’t mean a reduction in admin costs,necessarily, as now “medical professionals are doing a lot of the work such as choose and book, coding, and so on, that could be said to be market costs.”
OurNHS asked Kings Fund Chief Economist John Appleby if the recent influential Barker Commission on the future of health and social care funding had looked at the cost of the NHS market.
Appleby replied “no it didn’t. wld need to look at net change..might not be net ‘saving’ as you assume.”
“One problem is no study yet to test cost-effectiveness of market in NHS”, Appleby added.
His own Kings Fund 2011 study on the market ‘reforms’ to date merely said the cost was ‘expensive’ but ‘unknowable’.
Who is served by the lack of intellectual curiosity by these unaccountable ‘think tanks’ to whom the Department of Health has largely outsourced policy-making? Although their accounts are not very helpful, insiders tell me that the Kings Fund make a substantial proportion of their income from advising this sprawling bureaucracy how to deal with the permanent revolution of the marketplace.
Privatisation doesn’t work
If competition and markets improved health, perhaps the extra costs would be worth it.
We’ve had twenty years of being told the NHS should be run like a supermarket, most recently from M&S man Sir Stuart Rose.
And – as an inquiry convened by Debbie Abrahams MP found earlier this year, there’s scant evidence the market improves quality or health equity (and plenty of evidence it worsens both),whilst costing considerably more.
Just about the only academic study that claimed some ‘cost-effective’ benefits for NHS competition has been criticised for its “heroic” assumptions and failing to factor in the “whole system costs” of competition.
But then, we’ve known since the pioneering work of Nobel Laureate Kenneth Arrow in 1963 that markets in health care simply don’t work. Being a ‘customer’ of healthcare is not like being a customer of, say, oranges – it takes expertise that you and I simply don’t have, and the consequences of the wrong ‘choice’, or a provider closing down, are far more serious.
Bevan and Beveridge’s vision was for not for pseudo-‘choice’ but for local, skilled professionals making decisions on the basis of a ‘strong public sector ethos characterised by commitment and altruism’. They recognised only a publicly owned system could avoid ‘opportunistic behaviour by those who would seek to profit from illness’, with incentives to over-treat and over-investigate, stimulate patient demand through advertising.
Few health economists can agree whether NHS ‘productivity’ has improved, declined, or isn’t an appropriate measure. But evidence from the ground shows patient satisfaction and NHS staff morale are now declining rapidly.
For the cost of the market isn’t just financial. Patients are inconvenienced and even endangered as they are shunted between competing hospitals, GPs, community services and ambulances, all trying to dump costs on each other. The Francis report into the failures of care at Mid Staffordshire found that drive to market-friendly ‘Foundation Trust’ status had created a “supposed ethos of competition and commercial negotiation” which promoted secrecy and undermined co-operation between medical professionals.
Hinchingbrooke, the first NHS hospital to be fully handed over to the private sector – is still a financial basket case, despite having cut corners – and staffing – to the extent that everyone from the Royal College of Nursing to the Care Quality Commission are united in their condemnation of poor standards ofcare and demoralised staff.
Imagine what improvements to our healthcare could have been made, had NHS financial and leadership resources not been squandered on creating a market. As Paton comments, the ‘opportunity costs’ are huge.
So how do we rid ourselves of the creaking edifice of the NHS market?
The market system is now so entrenched it has been compared by demoralised staff to Stalinism.
The proposed Bill has already attracted support from Lord David Owen, Green MP Caroline Lucas and the Green Party leadership, Labour Parliamentary candidates, the National Health Action Party and the author of the recent minority Lib Dem report on the NHS, Charles West.
Getting rid of the market would be uncomfortable for the cadre of NHS managers, management consultants and think tanks whose main skill is permanent reorganisation. But it wouldn’t happen all at once. They’d have one last big job on their hands before retraining as something more useful to society, leaving a slimmed down management and a beefed up medical workforce to get on with the job of running an NHS in the interests of patients, not profits.
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About the author
Caroline Molloy is Editor of OurNHS and a freelance writer. In 2011/12 she was part of a successful campaign which reversed one of the largest planned NHS privatisations in the country, involving 9 Gloucestershire hospitals. Since then she has been campaigning alongside local and national groups to defend the NHS.
This article is published under a Creative Commons Attribution-NonCommercial 3.0 licence.