The creation of the NHS marked a decisive moment in the process through which the UK joined the family of north European social market economies. Efforts since Mrs Thatcher came to power to shift the NHS in the direction of a US profit-driven system have repeatedly run up against the fact that the integrated, taxpayer-funded NHS model provides some of the best care in the World at a lower cost than any of the alternatives. According to the World Bank, the UK spent 9.1% of GDP on health in 2013, compared to 11.3% in Germany, 11.7% in France, 12.1% in the Netherlands and 17.1% in the USA. At the same time, people in Britain live longer than people in the US and Germany.
This achievement may be threatened if Brexit goes ahead and trade policy comes to depend on a deal negotiated from a position of weakness with a Trump administration eager to promote opportunities for profit-seeking US corporations. The efficiency of the public-service model of health care should not be traded away, but used to provide the British public with the best health care in the World by increasing spending progressively to a level closer to the average for comparable advanced economy countries.
Funding health care
The fundamental problem for the NHS is not structure but rising costs resulting from increasing life expectancy and expensive new technologies and pharmaceuticals. Improvements in waiting lists and service quality were achieved between 1999 and 2010, largely because of a 94% rise in spending by the then Labour Government. But, according to the Institute for Fiscal Studies, growth slowed to 1.3% on average between 2009 and 2016 (compared to an average of 4.1% for the sixty years from 1955-2016). Demographic trends mean that funding must increase in real terms if the NHS is to continue to deliver a high quality of service. With the Government proposing to reduce funding per patient in real terms over the coming years, the outlook is extremely worrying.
Structure and Management
Despite strong opposition from health care professionals, successive Governments since 1979 have sought to sidestep this problem by repeated attempts at restructuring, which have opened the way to increasing marketisation. Overall, the benefits predicted to flow from these experiments have not materialised, as savings from reduced labour costs have failed to offset extra expenses resulting from duplication, tendering and contractor profit margins. The failure of marketisation came to a head in 2016 with the abandonment, three years into a ten year contract, of a flagship commercialisation project, which had transferred management of Hinchingbrooke Hospital in Cambridgeshire to Circle Holdings plc.
This brought home the difficulty of attracting private sector bidders for major contracts without paying over the odds. Splitting the buyer and provider functions and creating management units small enough to be put out to tender has also led to a jumble of different decision-taking bodies. For example, Foundation Trusts enjoy greater control over resources and spending than other parts of the service, which can encourage sub-optimal allocation of resources.
Meanwhile, according to the OECD, the Scottish Government has achieved results which are comparable to the NHS in England without much of the disruption and demoralisation that has afflicted the NHS south of the border. The Radical Party believes that an evolutionary approach should be adopted to reforming the organisation of the NHS with a view to consolidating its public service ethos and democratic accountability, while helping it to respond more effectively to new demands and ensuring continuing cost effectiveness. The Party believes that:
- public spending on the NHS and social care should be raised annually in real terms on the basis of regular periodical assessments of such factors such as the ageing of the population and the cost of new pharmaceutical and technologies;
- at the national level, consideration should be given to creating a bi-partisan oversight board responsible for protecting the foundations and integrity of the Service. Strategic management responsibility, within broad parameters set by the oversight board, should be transferred to elected regional health authorities, with powers comparable to those of the Scottish and Welsh Governments in the field of health;
- at the hospital level, changes should be introduced to ensure that health professionals have a central role in all decisions relating to clinical issues;
- the proportion of NHS services to be put out to tender should be limited to protect the integrity of the relationship with patients and the long term viability of core services;
- strict rules should be enforced within the NHS and general practice to ensure that all providers meet the same high standards of transparency and to prevent conflicts of interest, which may jeopardise patients’ trust in the health professionals they depend upon;
- fiscal measures to promote healthy living should be strengthened with a tax on sugar to help address rising rates of obesity and increased taxation on fossil fuels, which are known to be closely linked to heart disease and other potentially fatal health conditions.
Integrating health care and social services
The priority has now moved to integrating social and health care, which is set to be the focus for a fresh round of experiments over the coming years. Integration is a highly laudable objective, particularly with an ageing population, but only time will tell if the necessary resources will be made available. If not, there is a danger that it will simply end up as a means of transferring intractable problems from Westminster to cash-strapped local bodies. The fact that (according to the Institute of Fiscal Studies) spending in real terms on adult social care fell by 8% between 2009 and 2017 suggests that, particularly with a Conservative Government in power, this is a very real danger.
Recent statistics show a sharp rise in the proportion of community care contracts being awarded to tenderers from outside of the NHS, both profit seeking and not-for-profit. While profit seeking contractors still represent a relatively small proportion of the total, there is a risk that community-based providers will be progressively squeezed out. The Government claims to have created a level playing field for private and non-private tenderers but in fact local organisations committed to maintaining good employment conditions and a stable workforce face a handicap in competing with for-profit organisations, which operate across a multiplicity of sites.
Protecting the integrity of the Service
Private sector and not-for-profit providers, including GPs, dentists and pharmacists, have always played an important role in health care in Britain and will continue to do so. But marketisation inevitably leads to conflicts between profit maximisation and the interests of patients and to reduced transparency, denying patients information they need to make informed choices. These changes undermine public confidence and, by replacing collaborative relationships by internal competition, threaten the integrity and quality of the Service. An example of this is the loss of relationships and collective memory which occurs when stable in-house teams of medical professionals are replaced by a succession of short term agency staff. The Party proposes that:
- the minimum employment standards demanded from all tenderers should be raised and the requirement for mutual providers which have spun out from the NHS or local authority organisations, to re-tender regularly (currently a consequence of EU-based competition law) should be removed;
- private sector providers should be required to operate on a level playing field with the NHS in terms of transparency, to enable the public to choose on a basis of proper information and gagging clauses in medical compensation settlements should be banned.
The motivation and commitment of the people who work for the NHS are essential to delivering a high quality of service at a modest cost to the taxpayer. Any policy for the Service should build upon, and embed, this precious resource. The threat of Brexit poses a further challenge to staffing within the NHS – 10,000 doctors currently practicing in the UK qualified abroad in European Economic Area countries. A third of GP practices in England are currently unable to fill vacancies and, according to the BMA, 84% of practices say that excessive workloads are affecting patient care. The Government is now very unlikely to meet its commitment to increase the number of GPs by 5,000 by 2020. The Party believes that:
- in or out of the EU, a key part of addressing this issue must be a determined effort to increase the number of doctors and nurses who are educated in the UK. This will help to create a more stable workforce and end the scandal whereby clinics and hospitals waste precious resources on agency staff while talented candidates are denied the opportunity to qualify because of a shortage of study places;
- more resources are needed for training future GPs together with greater incentives for GPs who have gone part-time to bring up children to return to full-time employment. Hospitals and GP practices should continue to be able to recruit urgently needed staff from EU countries in the event of Brexit, on terms which are at last as good as at present.
According to the Education Statistics Authority, 25% of first year medical students in UK universities are from private schools – which account for only 7% of all school pupils. At the same time, research published in BMC Medicine, shows that pupils from non-selective schools performed better in medical examinations than those from private or grammar schools. Proactive efforts are needed to address this issue. The number of places to study medicine should be increased, helping to reduce the pressure to draw expensively trained health professionals away from lower income countries, where the shortage of medical expertise can be much more critical than in the UK.