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-style 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 (despite weaknesses in specific areas), 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 or Germany.
This achievement may be threatened if Brexit goes ahead and trade policy depends on a deal negotiated from a position of weakness with a US administration eager to promote opportunities for profit-seeking US corporations. The Radical Party believes that the efficiency of the public service model of health care and the relationship of trust it makes possible between health professionals and patients should not be traded away. Rather it should but used to provide the British public with the best healthcare in the World by increasing targetted spending progressively to a level closer to the average for comparable advanced economy countries.
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.
To address this need, the Party considers that the Government should be required by law to adjust public spending on the NHS and social care annually in real terms on the basis of assessments by the Office of Budget Responsibility of such factors such as the ageing of the population and the cost of new pharmaceutical and technologies, taking account of any efficiencies that can be achieved.
While there will always be opportunities to achieve greater efficiency, this should not be allowed to detract from the main priority, which is for better funding for the Service. This is forcefully underlined by a recent analysis by the King’s Fund of OECD data, which shows that in terms of the number of doctors, nurses and hospital beds per head, the UK ranked 19th, 16th and 18th respectively out of the 21 countries surveyed. The Government’s announcement in June 2018 that it intends to increase funding for the NHS over the next three years is welcome, but the Prime Minister’s admission that it is intended that this will largely be funded by savings she claims will result from Britain’s departure from the EU means that the outlook remains extremely worrying.
Structure and Management
Despite strong opposition from health care professionals, successive Governments since 1979 have sought to sidestep the funding problem by restructuring schemes, which have opened the way to increased marketisation. Overall, the benefits predicted to flow from these experiments have not materialised as savings from reduced labour costs have failed to offset extra costs 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 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 those of 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, at the national level, a bipartisan oversight board responsible for protecting the foundations and integrity of the Service should be created. 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. At the hospital level, changes should be introduced to slim down management and ensure that health professionals have a central role in all decisions relating to clinical issues. As part of the effort to improve the quality and efficiency of the service, resources should be made available to enable the UK to establish a lead position in the use of artificial intelligence in medical diagnosis and procedures.
Integrating Health and Social Services
The priority in the reform of the NHS has now moved to integrating social and health care, which has broad political support and 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.
One of the greatest strengths of the NHS is that, in contradistinction to the profit-driven US approach which Westminster politicians have been smuggling into our system piece by piece over the last 40 years, it is uniquely well-placed to promote health care in a holistic sense and is not just a service to cure disease. But achieving the goal of optimum health for all requires a recognition, first, of the close links between ill-health and deprivation and disadvantage, as demonstrated by plotting health outcomes against a map showing the level of poverty and unemployment. For example, Office of National Statistics figures show that the growth in regional inequalities in life expectancy over the last 20 years has led to a situation where a boy born in Blackpool, one of the poorest cities in the UK, can now expect to live 8.6 years less than a boy born in Chelsea and a girl born in Middlesborough, 6.9 years less than a girl born in Chiltern District.
The second, factor which needs to be taken into account in planning a comprehensive approach to promoting better health for all, is the need for political reform as a pre-condition for addressing some of the most important immediate causes of ill-health. While progress has been made in tackling smoking, other areas, such as alcohol abuse, illegal drugs and obesity, have proved more intractable, with clear evidence of the continued ability of powerful lobbies to block urgently needed initiatives. An integrated approach is needed involving education, hard-headed negotiations with the industries concerned and fiscal measures, with higher taxes on products which can clearly be shown to cause illness. At the same time, a determined effort should be made to improve services for mental health, with increasing life expectancy a rapidly growing issue, supported by an appropriate increase in the resources.
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. This undermines public confidence and, by replacing collaborative relationships with internal competition, threatens 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. To protect the integrity of the relationship with patients and the long-term viability of core services, the proportion of NHS services that are put out to tender should be reduced by 50% over an agreed timescale
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 every three years (which is currently a consequence of EU-based competition law) should be removed. 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. Private sector providers should be required to operate on a level playing field with the NHS in terms of transparency, to ensure quality of service and value for money and to enable the public to choose on a basis of proper information. As part of this, transparency, 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 practising 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 British Medical Association, 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. 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.
The Party believes that legislation should be introduced to require the Government to accept a responsibility for ensuring that sufficient medical professionals are available, and in place, to meet national needs. 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 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 stronger incentives for GPs who have gone part-time to bring up children to return to full-time employment. In addition, 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 least as good as at present.
SUMMARY OF PROPOSALS
Funding, Structure and Management
- require the Government by law to adjust public spending on the NHS and social care annually in real terms on the basis of assessments by the Office of Budget Responsibility taking account of the ageing of the population the cost of new pharmaceutical and technologies, and efficiencies achieved in the use of resources;
- create a national bipartisan oversight board responsible for protecting the foundations and integrity of the Service;
- provide for strategic management responsibility, within broad parameters set by the oversight board, to be transferred to elected regional health authorities with powers comparable to those of the Scottish and Welsh Governments;
- slim down hospital-level management and ensure that health professionals have a central role in all decisions relating to clinical issues;
- support the development of a leading role for the UK in use of artificial intelligence in medical diagnosis and procedures.
The Integrity of the Service
- reduce the proportion of NHS services put out to tender by 50% over an agreed timescale to protect the integrity of the relationship with patients and the long-term viability of core services;
- enforce strict rules 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 jeopardise patients’ trust in the health professionals they depend upon;
- raise the minimum employment standards demanded from all tenderers and remove the requirement for mutual providers spun out from the NHS or local authorities to re-tender every three years;
- require private sector providers to operate on a level playing field with the NHS in terms of transparency, to enable the public to make informed choices;
- ban gagging clauses in medical compensation cases to improve transparency.
- require the government to ensure that sufficient medical professionals are available, and in place, to meet national needs;
- increase the number of doctors and nurses who are educated in the UK to create a more stable workforce and end the scandal whereby clinics and hospitals are obliged to hire expensive agency staff while talented candidates are denied the opportunity to qualify because of a shortage of study places;
- increase the resources for training future GPs and provide stronger incentives for GPs who have gone part-time to bring up children to return to full-time employment;
- ensure that hospitals and GP practices can continue to be able to recruit urgently needed staff from EU countries whatever the outcome of Brexit, on terms which are at least as good as at present.
Health and Social Services
- support initiatives to improve the integration of health and social services provision for vulnerable patients, while ensuring that an appropriate level of funding is provided;
- promote healthy living by increasing taxes on products which can clearly be shown to increase ill-health and on fossil fuels which are closely linked to heart disease and other potentially fatal health conditions;
- make a determined effort to improve services for mental health and vulnerable elderly people and increase the resources available.