The creation of the NHS marked a decisive moment in the process by 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 with a top-down management structure 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 or Germany.
This achievement may be threatened if Brexit leads to trade policy depending on a deal negotiated from a position of weakness with a Washington administration focused on promoting opportunities for US corporations. The Party believes that the public service model of health care and the relationship of trust it encourages 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 protecting the integrity of the service and increasing targeted spending progressively towards 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 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 from an average of 4.1% between 1955 to 2016 to 1.3% between 2009 and 2016. Demographic trends mean that funding must increase in real terms if the NHS is to continue to deliver a high quality of service and improve the quality of services for mentally ill and elderly people.
To address this need, 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 must not distract from the main issue, which is that the Service needs more money. This is underlined by a recent analysis of OECD data by the King’s Fund, which shows that in terms 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 this will largely be funded by savings she claims will result from Britain’s departure from the EU does not inspire confidence.
Structure and Management
Despite strong opposition from health care professionals, Governments since 1979 have sought to sidestep the funding issue by restructuring schemes and increased marketisation. Overall, the benefits predicted to flow from these experiments have not materialised as savings from cuts in staff have failed to offset the cost of 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 highlighted 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 encourages 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 afflicting the NHS south of the border. The Radical Party believes that an evolutionary approach should be adopted with a view to consolidating its public service ethos and accountability while helping it to respond more effectively to new demands and ensuring continuing cost effectiveness.
The Party believes that a national 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 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 improving quality and efficiency, resources should be provided to help the UK establish a leading role 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 sensible objective, particularly with an ageing population, but if adequate funding is not provided there is a serious risk 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 this is a very real danger.
Statistics show a sharp rise in the proportion of community care contracts awarded over the last ten years to tenderers from outside 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. To address this issue, the minimum employment standards demanded from all tenderers should be raised and the requirement for mutual providers spun out from the NHS or local authorities to re-tender every three years removed.
One of the greatest strengths of the NHS is that its mission is to promote health care in a holistic sense and not just to treat disease when it occurs. But achieving the goal of optimum health for all requires recognising the close relationship between poor health outcomes and deprivation, poverty and unemployment. For example, Office of National Statistics figures show that rising inequality between different parts of the country 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 is the need to tackle political obstacles to achieving better health for all. While steps have been made in the face of stubborn opposition in tackling smoking, progress in addressing alcohol and pollution-related illness and obesity has been impeded by the continued ability of powerful industry lobbies to block urgently needed measures. An integrated approach is needed involving education, hard-headed negotiations with the industries concerned and practical measures to reduce the use of fossil fuels, alcohol and sugar, which can clearly be shown to cause illness.
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 more extensive 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 when 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 (a consequence of current EU competition law) should be removed. Strict rules should be enforced within the NHS and general practice to prevent conflicts of interest, which may undermine 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 enable the public to choose on a basis of proper information. As part of this, 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. Any policy for the Service should embed and build upon this precious resource. The Party believes that legislation should be introduced to require the Government to ensure that sufficient medical professionals are available to meet national needs, subject to an annual review by the oversight Board.
A third of GP practices in England are currently unable to fill vacancies and, according to the British Medical Association, 84% of them report 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, with NHS Digital reporting that the number of full-time equivalent GPs fell by 523 between March and June 2018.
More resources are needed for training future GPs but, with a 2018 King’s Fund survey finding that 47% of GP trainees now intend to work part-time, training places in themselves will not be enough. A strategy urgently needs to be agreed to address this problem, encompasing work loads, stress, development opportunities and stronger incentives for GPs who have gone part-time to bring up children to return to full-time work. In addition, hospitals and GP practices should continue to be able to recruit urgently needed staff from EU countries on terms which are at least as good as at present.
In or out of the EU, a determined effort must be made to increase the number of doctors and nurses educated in the UK, bolstering NHS staffing and at the same time reducing the number of expensively trained health professionals drawn away from lower-income countries, which often face a critical shortage of medical expertise. This in turn 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.
At the same time, to optimise the use of human resources and improve quality of care, a focussed drive should be made to make sure that the UK plays a leading role in the development and application of artificial intelligence in medical diagnosis and procedures
SUMMARY OF PROPOSALS
Funding, Structure and Management
- adjust spending on the NHS and social care annually on the basis of assessments by the Office of Budget Responsibility, to reflect rising demands and costs and greater efficiency;
- create a national bipartisan 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;
- slim down hospital-level management and ensure that health professionals have a central role in all decisions relating to clinical issues.
The Integrity of the Service
- reduce the proportion of NHS services put out to tender by 50% to protect the integrity of the relationship with patients and the long-term viability of core services;
- enforce strict rules within the NHS, general practice and the private sector to ensure that all providers meet the same high standards of transparency and to prevent conflicts of interest and ban gagging clauses;
- raise the minimum employment standards demanded from all tenderers and remove the requirement for mutual providers spun out from the NHS to re-tender every three years.
Health and Social Services
- support initiatives and funding to improve the integration of health and social services provision for vulnerable patients;
- promote healthy living by increasing the cost of fossil fuels, sugar and alcohol, which can clearly be shown to increase ill-health;
- improve services for mental health and vulnerable elderly people and increase the resources available;
- support the development of a leading UK role in the use of artificial intelligence in medical diagnosis and procedures.
- require the Government to ensure that sufficient medical professionals are available to meet national needs;
- increase the number of doctors and nurses educated in the UK to create a stable workforce and reduce the need to hire expensive agency staff;
- increase the resources for training future GPs and provide stronger incentives for GPs who have gone part-time to return to full-time employment;
- ensure that hospitals and GP practices can continue to recruit staff from EU countries on terms which are as good as at present.