Author: docjon1415

by Christopher Thomas. Pluto Press

This book provides a helpful and eminently readable overview of ‘health’ and how a government with a ‘health justice agenda’ might effect meaningful change. ‘The left’ (a troublingly amorphous concept that casts the Royal Colleges in the role of key institutions of the ‘health labour movement’) is castigated for being romantic and defensive rather than innovative and visionary, placing a narrow focus on health services rather than the more important social determinants of health. Some arguments appear overstated for rhetorical reasons, for example: “We believe in 1948 as an ultimate victory for the left on the health agenda”. This disregards justified and longstanding criticism of the NHS by progressives that it was a ‘sickness’ service rather than a ‘health’ service, and that some elements such as mental health were never given the investment they warranted. The author also acknowledges that Bevan’s plan did not include a universal public health service.

In any case, few would now look at the current state of the NHS with its record waiting lists, staffing crisis, relatively poor outcomes and increasing penetration by the private sector, and not reflect that the ‘ultimate victory’ may yet prove to have been only a temporary respite. The Just Treatment ‘NHS New Deal’ (https://www.nhsnewdeal.org/) is singled out as an exemplar of a myopic fixation on the NHS (exacerbated by covid), and yet a glance at this organisation’s website shows it also has an international focus including vaccine equity and challenging the profiteering by big pharma. There is no mention of last year’s People’s Covid Inquiry (https://www.peoplescovidinquiry.com/) which critically examined the government’s response to the covid pandemic, but also explored health inequalities and in fact opened with internationally renowned Michael Marmot as an expert witness.

The book is divided into sections on the NHS, social justice, economic issues, social care, sustainability, and finally, a new deal for public health. Work on health inequalities by pioneers such as Marmot, Kate Pickett and Richard Wilkinson is duly acknowledged. The section on social care is rightly critical of the limitations of Labour’s National Care Service (“the NCS does not sufficiently change the nature of care, the power relationships that define it, or the level to which institutionalised and paternalistic care dominates provision”) and advocates a much broader approach, similar to the campaign for a National Care Support and Independent Living Service (https://nacsils.co.uk/).

There are a couple of minor if surprising errors. It is stated that “Since 2010, about 10,000 hospital beds have been closed in England”, whereas according to King’s Fund data around twice this number were lost (https://www.kingsfund.org.uk/publications/nhs-hospital-bed-numbers#:~:text=Key%20messages,bed%20numbers%20in%20recent%20years). Of less importance is the attribution of the Black Death to a virus rather than the bacterium Yersinia pestis (https://www.cdc.gov/plague/index.html#:~:text=Plague%20is%20a%20disease%20that,an%20animal%20infected%20with%20plague).

The author makes a cogent plea that health improvement and health justice require looking beyond health services to a public health system as a whole. This is perhaps the key message overall for health campaigners. The issue of affordability is dealt with well, although there is little on reformation of the tax system as a way to finance public services. While the author distances himself from the suggestion that the book is really a polemic with a Labour Party needing “a far more compelling vision”, statements such as “the leftist strategy in health has therefore become defined by maintaining the status quo”, leaves little doubt as to exactly where the barbs are aimed. If we agree that it is conditions of social injustice that make us sick, the questions remain as to whether democratic socialism is up for seriously challenging the dominance of those businesses and corporations who profit from our ill health, and what might be revealed about the balance of power in the course of such a struggle. Even more reason to rally the troops around defending and rebuilding the NHS perhaps, while setting this in the context of a much broader vision of public health as outlined in this book.

John Puntis

Co-Chair, Keep Our NHS Public

by John Lister and Jacky Davis (eds.). The Merlin Press Limited, Dagenham, 2022 www.merlinpress.co.uk

Like Woody Guthrie’s guitar (a ‘machine for killing fascists’), ‘NHS Under Siege’ is intended not just to educate, but as a weapon to inform and strengthen the fight for the NHS and social justice. Edited by two veteran campaigners who also wrote the first two thirds of the book, and with a forward by the writer Michael Rosen, it has contributions from, trade unionists, academics, public and child health experts, health policy analysts and covid bereaved relatives. First of these out of the blocks is Michael Marmot reminding us that while the NHS must be defended against attack, there is also a need to focus on the conditions that make people sick in the first place – the social determinants of health and health equity.

Even before the pandemic, life expectancy increase had slowed dramatically, health inequalities were increasing and life expectancy for the poorest was getting worse. This was the direct result of fiscal policies that led to massive decreases in public expenditure and dramatic increases in child poverty. A major section of the book draws on the People’s Covid Inquiry, elegantly summarised by Jacky Davis, exposing lack of preparedness, sluggish response, failure to protect workers and vulnerable, preference for the private sector, cronyism and corruption, and lack of accountability for tens of thousands of covid deaths.

The adverse effects of austerity policies are explored in detail together with the ever present and misleading spin from government. For example, £34bn funding marking the 2018 NHS 70^th birthday was in fact only £20bn in real terms and the decade ended with 9000 acute and general beds closed, 22% of mental health beds lost, a pre-covid waiting list increased from 2m to 4.5m, deliberate lying to the public about the prospect of 40 new hospitals, and unacknowledged needs related to a four million increase in population. The NHS now faces an existential crisis both from ten years of austerity that wiped out the growth of the previous decade and the huge challenge while ill-prepared and under resourced of dealing with the covid pandemic.

The authors argue that the ‘besieging forces’ (right wing politicians, private health care corporations, etc.) don’t want to replace the tax funded system, but to exploit it more fully by ensuring the greatest flow of profitable activity to private providers, while also maximising the numbers of patients who will opt to pay for elective treatment rather than face long delays. A core NHS would be maintained to treat emergencies, provide care for maternity, complex and chronic cases, train staff and foot the bill for the poor, sick and elderly. Ministers continue to gaslight the public about ‘spending more than ever before’ on health when the truth is quite the reverse. Each year since 2010, the health budget has grown less than the previous average increase in spending, bringing real terms cuts as resources lag behind rising costs.

Key expectations that there would be a ‘national upgrade in prevention and public health’ set out in the 2014 Five Year Forward View for NHS were not met, while service providers have been overwhelmed by a slew of undeliverable objectives, lacking the investment and workforce required to make them feasible. Policies, decisions and circumstances that have brought us to this situation, the actual and real term cuts in spending, the fragmentation, the privatisation, the so-called reforms, reorganisation and plans that have weakened the NHS and made it more dependent on the private sector, including the most recent reorganisation into Integrated Care Systems, are documented and deconstructed.

A devastating recent report from the parliamentary Health and Social Care Committee has characterised the current situation in the NHS as the ‘greatest workforce crisis in its history’, castigating government for an absence of credible strategy, with critical gaps in almost every area of care. Health policy analyst Roy Lilley concludes the book by pointing out that without a workforce plan the NHS will fail, leading to a poor service for poor people. While he also opines that ‘no one plans to fail, they simply fail to plan’, it is difficult to read this book and not conclude that government policy does indeed amount to planned failure.

The authors stress that the siege of the NHS has been opposed, and their intention is to arm and fuel the resistance. Defences could be strengthened now by new money, above inflation pay rises for staff, and all investment being channelled into reopening, rebuilding and expanding NHS capacity rather than squandering on private providers.

This book should be read by anyone interested in both defending and rebuilding the NHS and in addressing health inequity as a matter of social justice, packed as it is with facts and insight presented in an accessible and well referenced form. It should also be read by anyone with any pretension to wanting to examine critically the claim by the conservative government that it cares for and has been generous to the NHS. John Lister reminds readers of the long history of campaigners fighting to defend and improve services, going back to the 1970s. This book should help inspire new generations of activists as well as stimulate the development of novel strategy and tactics. The question is raised that If the mission of the NHS is to put the equity of health and wellbeing at the heart of all policy, how much more should this be true for the whole of society? Read the book and join the fight.

John Puntis

Co-chair Keep Our NHS Public

Your editorial summarises the terrible situation in general practice: declining numbers and declining passion for the role, with poorer outcomes for all (“A dearth of GPs is threatening the country’s health”). We in Doctors in Unite, part of Unite, have recently published our charter to revitalise general practice. This requires a party in government committed to re-instating the NHS as a public service, ending commercialisation and fragmentation, and abandoning public sector cuts.

We want to see practices with a wide primary care team, covering about 10,000 patients, within neighbourhood health committees. Each neighbourhood, with doctors qualified in both primary care and public health, would work with community development workers empowering communities to collectively address local health issues. We want improved working conditions for GPs, career progression and finite working days. We must ensure access proportionate to patient need, reversing the current position, with support for continuity of care. Let’s make the job of general practice attractive to patients and practices again – it would transform our NHS.

Brian Fisher, Doctors in Unite
London SE14

Link to letter here