A winter’s tale – no room on the ward.
Winter is upon us, as it tends to be at this time of year. It should be no surprise. Yet after two successive increasingly severe winter crises, the NHS is no better resourced and barely better prepared to prevent a third.None of the fabled ‘extra funding’ talked up as a 70th “birthday present” to the NHS in Philip Hammond’s latest austerity budget is available until next year, and in many cases last year’s ‘winter crisis’ stretched on deep into the summer or ran unbroken into autumn.
After 8 brutal years of effectively frozen real terms funding, which has fallen falling ever further behind growing need for treatment for a growing population with a rising proportion of more dependent older people, the NHS has too few beds, too few staff to open more, and too little in the way of community and primary care (GP) services.
To make matters worse the halving of council budgets since 2010 has brought cash-starved, privatised, under-staffed and often dysfunctional social care services, with “eligibility criteria” designed to limit care to those in most extreme need, and offering no possibility of preventive care to support people and keep them out of hospital.
Even by November, before the coldest weather, the numbers of emergency patients left waiting over 12 hours for a bed have doubled in England compared with November 2017. Over a third of hospitals were running at 97% occupancy or higher, with ten hospitals running more than 99% full – well above the recommended 85% occupancy target agreed by professionals for safe care, and even above the higher 92% target set by NHS Improvement last winter.
In dozens of hospitals – many of them in rural counties such as Worcestershire, Shropshire, Norfolk, Cambridgeshire and Warwickshire – emergency ambulances are facing delays in handing over patients who have been rushed in for treatment, only to queue behind other ambulances outside already full hospitals.
The problems facing acute hospitals are echoed in mental health services, where despite limitless tides of gushing rhetoric for the past 20 years funding has remained inadequate or even fallen in some areas as a share of NHS spending, numbers of nursing staff are still massively lower than they were in 2010, and children and adults with urgent needs for in-patient treatment are transported often hundreds of miles in search of a free bed.
In primary care, too, where 90% of first contacts are made with the NHS, the pressures have been growing. A survey by the GP magazine Pulse revealed that more than half of GPs said last year’s winter crisis led to avoidable emergency admissions among their patients. 43 of the 750 respondents – almost 6% – said the pressures led to the avoidable death of a patient.
GPs provided an extra 345,000 appointments last winter above the level they were paid for – but still could not prevent long and frustrating delays in many cases for patients waiting to see their doctor.
Meanwhile as if to advertise the government’s lack of concern for the longer term health of the population, funding for public health services, which are supposed to help educate, promote healthy living and prevent illness, is once again being cut back, while the long term rise in life expectancy since 1945 has not only halted but started to reverse.
Underlying all these problems are two fundamental problems, compounded by a third.
The first – and most intractable – problem is the massive, growing staff shortage, with over 100,000 vacancies including over 40,000 nursing posts across England’s NHS. This has been exacerbated by the Brexit referendum result which brought a collapse in applications from many EU countries along with a shameful increase in insecurity and abuse experienced by tens of thousands of qualified EU nurses and doctors, many of whom have been leaving.
Add to this the short sighted government decision to save money by axing the bursaries that helped cover the living costs of nursing and other professional courses. This has resulted in a predictable fall of over 30% in applications for courses, but also an increased proportion of students coming from school leavers and younger age groups, more likely to drop out or take other jobs, and missing out on the mature students who have been so valuable to the NHS.
The difficulty of the staffing crisis is that even if the NHS was given all the money it wanted, and even if the long term pay cuts inflicted on these staff were reversed, it cannot instantly magic up tens of thousands of trained staff, since health professionals take years to train, and inadequate numbers have been trained for many years.
The bursaries need to be reinstated and training expanded, but there is also an urgent need to sweep away the reactionary barriers that have been created to recruitment of staff from overseas, and especially keep open the free movement of EU health professionals, alongside an urgent, systematic and coherent effort to win back many of the trained staff who have left the NHS burned out or frustrated by pressures and workload.
The second fundamental problem is the level of funding, which has been barely increasing above inflation since the start of the Tory austerity regime in 2010, and lagged way behind the 3-4% real terms increase each year required to keep pace with population and cost pressures.
The result is an NHS weighed down by overt or covert debts. Hospital trusts are running an underlying deficit each year of up to £4 billion, and have been propped up in many cases by ‘loans’ which now add up to more than £12 billion. The gap is now so wide that even the “birthday present” of an “extra” £20 billion over five years is barely enough to keep the system afloat, and nowhere near enough to raise pay, restore the bursaries, improve mental health, expand community services, or reopen or build the extra beds needed in many areas to cope with rising demand.
And without all of these issues being resolved, and radical action to bring social care into public ownership and control, with full funding and services free at point of use in place of the current means tested charges, the aspiration of NHS England for “integration” of health and care services remains a pipedream.
Both of these fundamental problems have been compounded by the government’s underlying privatisation agenda – not seeking to sell off the whole NHS as Thatcher did with the utilities in the 1980s, but finding ways to carve out profitable opportunities for the private sector to take a share of the public budget. This was the logic behind the disastrous 2012 Health and Social Care Act, which has resulted in a colossal waste of management time and resources in a fragmented, dysfunctional system created to formalise a competitive ‘market’ in health care, and compel local Clinical Commissioning Groups to put services out to tender.
The contradiction has been that the cash squeeze is now so severe that few if any private companies are now even bidding for the larger contracts put out to tender, since they see no way they can make a profit. But even where NHS trusts win the contracts, the damage is still done: services are fragmented and often cut back to save money, competition prevails while population needs are ignored, strategic planning is excluded, and there is less and less accountability to local communities.
The legislation makes nonsense of the meaningless mantra of “integration” which is repeated by NHS England. We need action to reverse the reactionary 2012 Act, end the requirement to contract out services, roll back privatisation, make the Secretary of State accountable for the NHS, and ensure local communities have real influence on their health care.
So what needs to be done to fight back for the NHS? Clearly we cannot win all our demands without a change of government and a concerted drive against all forms of austerity, but there are things we can do, and the main coalition that has emerged to coordinate efforts is Health Campaigns Together, now 3 years old.
For the last two winters Health Campaigns Together has worked with local campaigners, trade unions and others to build major protests over winter pressures (March 4 2017, February 3 2018). This winter we will instead be encouraging local protests and mobilisations, but also focusing strongly on the fight to Make Services Safe For All (with a strong focus on staffing levels, adequate bed numbers and systems) and developing a new campaign for social care, as well as fighting all forms of privatisation.
In this time of political instability we need not only a national campaign but organisation in every area to intensify the pressure on local MPs and councillors to stand up for services and put pressure on government to halt threatened closures and downgrading of services. This has already yielded results in many areas, with councils beginning to invoke some of the residual powers they have to block changes through their health scrutiny committees, and MPs clearly forced to lobby behind the scenes to avoid embarrassing cutbacks.
HCT is not party political, but welcomes affiliations and donations from campaigns, Labour and other political parties, trade unions at national, regional or local level, pensioners groups and any organisation wanting to fight to defend, extend and improve our NHS as a public service: check us out at www.healthcampaignstogether.com. Individual activists can join local branches of Keep Our NHS Public – www.keepournhspublic.com.
Let’s come out fighting in 2019 for the NHS we all need and deserve.
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