The only future for the NHS after COVID-19 is a return to its founding principles

The COVID-19 pandemic illustrates the vital importance of a comprehensive, publicly funded and universal health service. The choices we make during this crisis will shape the future of the NHS and our wider society.

We are already limited by poor decisions made before the virus struck. The Conservative’s ‘hostile environment’ policy, where people with a precarious immigration status risk deportation or destitution if they seek NHS services, means there may now be considerable apprehension to access necessary care. Though coronavirus treatment is exempt from charging for those without documentation, this message is likely to be lost.

When more beds were needed, rather than requisition private hospitals the government struck a deal where beds are rented for £300 each, per day. This amounts to a public sector bail out of private hospitals that the NHS should never have to pay. These beds could be utilised in the public interest; instead they are rented at public expense.

The government then wrote off £13.4bn of NHS debt. It is disingenuous to call this debt. It represents money that has been rightly spent on patient care, and the government’s actions acknowledge this with a trick of accounting. It is also only a fraction of the shortfall in NHS funding over the last ten years of austerity.

A sincere approach to the NHS’ debt would be to cancel Private Finance Initiative payments. £2bn was paid in 2016/17 in PFI debts, and repayments will continue every year until 2050. This lost wealth represents around 2% of the annual NHS budget. It could be reinvested to improve the nation’s health but instead vanishes into private hands. The same is true for private buildings used for NHS services. There is an opportunity to return these to the ownership of the public they serve.

Fragmentation, cuts and creeping privatisation have all contributed to the difficulties in our response the pandemic. More than 17,000 beds have been cut from the 144,455 that existed in 2010. The UK has a lower number of critical care beds per person than Italy, France, Spain, Germany, the USA, Japan, or South Korea. Years of underfunding led us to this moment. The PPE distribution fiasco shows the inability of the private sector to provide the service needed. Cutting warehouse capacity in order to prioritise profit means private distribution companies cannot now supply health and social care workers with the person protective equipment they need.

The hundreds of billions of pounds made instantaneously available in response to coronavirus shows the transformative power of the state to provide a crucial safety net for all of us. We can afford a far fairer society than the one we became accustomed to. Rapid changes to manufacturing capacity to produce ventilators, dialysis machines, PPE and other socially useful products demonstrates that an economy based on public ownership, planning and democratic control could meet the needs of people across the world, unlike the chaotic response of the free market.When this crisis eventually subsides, the public must not be made to pay. We must not return to more austerity.

We also cannot emerge from this pandemic and continue to ignore the harm caused by environmental destruction. The delayed, incomplete initial response to coronavirus echoes our apprehension to face the challenge presented by climate change. We should confront the runaway economic expansion that created the conditions for previous, current, and perhaps future outbreaks. We have an opportunity to live within our planetary means.

We could recreate our health and social care systems based on need not profit. We could choose to reduce inequality permanently. The reset button on society has been pushed – what happens next is up to all of us.

Despite coronavirus and clapping, the Tories remain hostile to a public NHS

In recent weeks we have among others seen Boris Johnson, Matt Hancock and members of the Royal family (all of whom it’s safe to guess have never used the NHS) joining in the public applause for key workers. Additionally, there have been a number of structural changes and commitments to increased funding that make it feel as if the strengths of a truly public National Health Service are now being acknowledged, together with an implied criticism of many of the reforms of the last near decade.

Taking over CCGs

On March 23rd it was announced that NHS England was taking on extensive special powers normally held by clinical commissioning groups to support efforts in the face of coronavirus. Dr. Tony O’Sullivan (co-chair of Keep Our NHS Public) commented on the NHS England website: “at this time of national tragedy, we should remember the function of a national health service and how politicians and the seismic restructuring policies in the Long Term Plan have weakened the NHS. I hope that this ends the fragmentation into 42 separate commissioning units and integrated care systems. How wrong that strategy has been. As we welcome some steps towards the re-integration of the NHS in our hour of need, let us not forget the follies that weakened it and that have put NHS staff and the public at risk. We need the NHS to go forward as a single coordinated public service, there for everyone in time of ‘war’ and nurtured once again in post-COVID-19 peacetime.”

Taking over the private sector?

These special powers will be in place until at least the end of 2020, and one of the principal reasons for them was to gain access to independent sector beds. Taking over the independent sector in times of national need is to be applauded. Spain for example has just requisitioned its large private sector. In stark contrast, however, the UK government is paying private hospitals £300 per bed per day. Business analysts have observed that this is a huge boost to independent hospitals. A private hospital working on an NHS tariff at 100% capacity is far better than conducting private medical insurance work at 50% capacity.

Abolishing debt?

The government announced that from April 1st it would “write-off” £13bn of historic debt across the NHS. In recent years financially struggling trusts have been routinely forced to seek emergency bailout loans from the Department of Health and Social Care. Last year, trusts’ total debts reached £14bn, of which £10bn was related to emergency loans. While Matt Hancock declared this a “landmark step” made by himself to help the NHS COVID-19 response, the plans had in fact already been discussed at a January meeting called by NHS England and NHS Improvement, and had been under consideration for at least 20 months. 

As tax expert Richard Murphy explains, the government has not written off hospital debt. “All it did was make a book-keeping adjustment. What it actually did was allow NHS trusts to record the sums they had spent for the populations they served as having been funded by central government when previously the government were claiming they had overspent.”

John Lister writing for the KONP website also noted that “it’s like a gang of burglars seeking gratitude after handing back some of the jewels they have stolen. £13.4bn averages to a refund of just £1.3bn per year for the last ten years – far less than the real terms cuts that have been imposed by the virtual freeze on funding while the population and its health needs have grown.” It would be much more valuable to the NHS if the government were to write off the huge outstanding payments for new buildings paid for through the Private Finance Initiative, but strangely, Rishi Sunak does not seem to be stepping forward with this proposal.

Xenophobia is alive and well

Before the pandemic, the UK had only 4100 critical care beds, 6.6/100,000 population compared with Germany’s 29.2. An urgent need to find more ventilators was identified at the start of the outbreak, yet Downing Street chose not to participate in an EU scheme to source such vital equipment, leading to the charge of putting “brexit over breathing”. The government’s attempts to justify this through claims of having accidentally missed a deadline due to communication errors were quickly exposed as groundless by EU officials.

Despite the need for both trust and a unified response to the crisis by members of the public, it is notable that the hostile environment in the NHS has not been lifted. As one member of KONP writing in the British Medical Journal observed, “it is simply not good enough for the UK to add the novel coronavirus to its list of exemptions from charges, which few people will know. To tackle this epidemic and protect everyone’s health, all barriers to accessing NHS treatment – including charges and reporting of debt to the Home Office – should be suspended immediately.”

References to COVID-19 as the ‘Chinese virus’ and promising a reckoning with China after the pandemic are diversions of attention from the failings of our government ministers. Zoonoses (infectious diseases that spread from animals to humans) are linked to climate change and intensive farming methods among other things, and are destined to be a recurrent event. Michael Gove would do well to reflect that not long ago Bovine Spongioform Encephalopathy resulted in the slaughter of 4.4 million cows in the UK and was responsible for variant Creutzfeldt-Jakob disease in humans. The World Health Organisation has warned against use of the term ‘Chinese virus’ saying that it could lead to racial profiling against Asians when “there is no blame in this”. In the UK we have already seen reports of Asian people being physically attacked in the street. 

What next?

Writing in the nineteenth century in his book The Housing Question, Frederick Engels made a highly relevant comment on the self-interest that motivates those who are in control of society through virtue of their wealth and position. “Capitalist rule cannot allow itself the pleasure of creating epidemic diseases among the working class with impunity; the consequences fall back on it and the angel of death rages in its ranks as ruthlessly as in the ranks of the workers.” 

Having said that, the competence of the ruling elite in preventing and controlling epidemics is always in doubt, since their desire for profit is in opposition to any inclination to spend money on public services until it is too late. Thus an opportunity to avert a crisis is lost, and a pandemic that could have been limited if planning advice had been implemented and intervention had been timely must instead run its miserable course. We have known for the past 13 years, for example, that a pandemic at least as lethal as coronavirus represented an ever present major threat.

At the same time we can be sure that history will be busily rewritten in order to exculpate ministers and make sure any temporary steps towards ‘nationalisation’ of services are quickly reversed. There may even be calls to continue the restrictions on civil liberty for much longer than the medical situation necessitates. 

Charles Moore (former editor of the Daily Telegraph, where he was Boris Johnson’s exasperated boss) is jockeying for position in this vanguard, explaining to readers that it is in fact deficiencies in the public sector that has brought the country to lockdown. In a sense Moore is correct, but for the wrong reasons. It is the underfunding and weakening of the NHS at the hands of the Tories that has made it much less able to deal with the current crisis, making lockdown even more crucial in order to limit demand. We can also expect to hear from other ideologues about how our small and parasitic private sector came to the rescue of the NHS in its time of need.

However much the Tories are now clapping for our NHS, we must remember that they are fundamentally opposed to public services, and will soon forget their panic and revert to form. A former Tory insider, now disillusioned with the world view that anything funded by the state is wrong (except of course infrastructure that furthers the interests of the rich), has written a tell-all piece stating as much.

Our job as health campaigners is to now make sure the right lessons are learned during the coming weeks and months. We need to keep the Tories on the hook, and harness the public anger which will no doubt grow over time. We must rally the vast majority of society around our vision of a health and social care service that exemplifies a more just, equal and caring society. 

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.

‘Groundhog day’ in the NHS means death and despair for thousands

Recent performance figures show that it is groundhog day once again in the NHS. A series of unwelcome events (missed targets) recur in exactly the same way. But behind these statistics are human stories of unnecessary suffering, that shame those politicians who have tenaciously supported the failed Tory policies of the past ten years.

A classic model of an organisation’s defenses against failure is a series of barriers represented as slices of Swiss cheese. The holes in the slices are weaknesses in individual parts of the system, and are continually varying in size and position across the slices. When a hole in each slice momentarily aligns, a hazard passes through all of the slices leading to a failure.

Patients are now tumbling through the huge holes in primary care, ambulance services, A&E, and social care every minute. If patients cannot be discharged because of inadequate social care, bed occupancy rises. A&E is then filled with those needing admission but with nowhere to go, and the new specialty of ‘corridor nursing’ is created. Since A&E is packed with patients, waiting times for assessment and treatment increase and the four hours target becomes even more elusive. Meanwhile, ambulances are unable to handover sick patients and queue outside instead of being able to respond promptly to further call outs.

While NHS England SitRep reports give some of the picture, the first publication from the Royal College of Emergency Medicine’s (RCEM) 2019-20 Winter Flow Project indicates that existing data does not always reflect the true scale of the problem. RCEM figures show that in the first week of December, over 5,000 patients waited for longer than 12 hours in the Emergency Departments of 50 Trusts and Boards across the UK – equivalent to a third of the acute beds in England. From the beginning of October 2019 over 38,000 patients had waited longer than 12 hours for a bed at sampled sites across the UK – yet data from NHS England reported that in England alone, a total of only 13,025 patients experienced waits over 12 hours since 2011-12.

The reason for the difference is that the RCEM correctly counts 12 hour waits from the moment a patient arrives in A&E – which is how it is measured in Wales, Scotland and Northern Ireland – but the NHS officially only records 12 hour waits from when doctors make a decision to admit the patient.

Data (as yet unpublished) by former RCEM vice-president Dr Chris Moulton, and former RCEM president Dr Cliff Mann, was widely reported in the press last December. Their study analysed the care received by more than four million people who attended A&E in England over the past three years. The findings indicated that 960 out of 79,228 patients who had to wait around six hours died as a direct result of the delay. One in every 83 people who have a six hour or longer wait to be admitted will die due to the delay in them starting specialist care.

Similarly, 855 people died over the past three years because they waited about seven hours, as did 636 others who faced delays of at least 11 hours. The researchers concluded that the deaths were entirely and solely caused by the length of wait, and not by the patient’s condition. This is the first research worldwide to calibrate the risk of death for trolley patients by the number of hours waited. According to research seen by the Guardian, 5,449 people have lost their lives since 2016 as a direct result of waiting anywhere between six hours and 11 hours. Findings also showed that the chances of dying increased sharply the longer the wait, rising to one in 30 for patients whose admission is delayed for 11 hours.

John Kell, the head of policy at the Patients Association, said:

“These results are deeply shocking and very worrying. Patients are clearly suffering tragic consequences as well as loss of dignity and discomfort from spending far too long waiting on a trolley for care. This is as a direct result of sustained underfunding of the NHS and social care and ongoing shortage of hospital beds. Despite the unstinting efforts of NHS staff, patients can no longer be sure of receiving safe or dignified care if they need to be admitted to hospital. This is an entirely needless and completely unacceptable situation.”

Dr Nick Scriven, the former president of the Society for Acute Medicine, was also quoted in the Guardian as saying:

“The exact numbers in this study should be a sobering reminder to all that these risks are occurring in some hospitals on a daily basis and, apart from the obvious loss of dignity of being kept in a corridor, there are proven safety risks as well. The risks will continue until overcrowded hospitals have the beds and staff they need.”

The RCEM report also showed that only 69% of patients were seen within four hours across 50 hospitals, the worst performance in the five year history of the Winter Flow Project. This was in accord with NHS England SitRep data up to December 2019, with similarly shocking figures across a range of other indicators. In January 2020 only 82% of patients at all types of emergency departments were seen within four hours, against the target of 95%. Only one out of 118 major A&E departments that submitted performance data met the four hour target.

The total number of A&E attendances exceeded 2.1 million, about the same as 2018-19 despite efforts to redirect patients away from A&E. 100,578 patients spent more than four hours on a trolley from a decision to admit to actual admission – this is the highest since records began. 2,846 patients had a trolley wait of over 12 hours, which is more than four times higher than in January 2019.

Dying due to having to wait an unacceptable amount of time for emergency medical attention is not confined to those on trolleys. There have also been plenty of examples where patients have died in the back of ambulances queuing to access the hospital, or while waiting for an ambulance to arrive. In December, a 47-year-old woman from Cwmaman in south Wales suffered a cardiac arrest in hospital after having to wait 6 hours on the pavement for an ambulance.

The longer a patient waits, the higher the risk of complications and fatality. According to a BBC investigation, delays for 999 ambulance calls affect one in 16 emergency cases in England. While long waits for immediately life threatening cases were unusual, long waits for other emergencies were much more common, including patients suffering from heart attacks, serious injury, stroke, sepsis, major burns and fits. There were 385,000 waits of over an hour from January 2018 to September 2019, out of just over six million calls.

In November 2019 the British Medical Association analysed current performance data and trends, predicting that the NHS was on track to endure its worst ever winter as pressure on services intensified. It said that a lack of recovery from the summer, staff shortages exacerbated by pension tax legislation forcing senior doctors to work fewer shifts, and a focus on Brexit planning rather than winter preparedness risked creating a “perfect storm”.

It also warned that particularly cold weather and significant flu outbreaks could exacerbate these further, urging the NHS to increase its bed stock before winter. However, even if new, promised hospitals eventually materialise, these will not solve the bed crisis. The NHS is now haunted by the spectre of a coronavirus pandemic, with assurances from the Secretary of State for Health and Social Care that it is “well prepared” being met with some scepticism. Long waits in A&E clearly have the potential to increase the spread of the virus.

The NHS has lost 17,000 beds since 2010 as a result of cuts to services or mergers, leaving the health service with the lowest number of beds ever recorded. A&E doctor and member of Keep Our NHS Public Tom Gardiner says:

“Our A&E staff are working flat out in the face of an ever-increasing demand for services. Cuts affecting our hospitals, our GP surgeries and our social care system have led to a situation where vulnerable elderly patients are left waiting for hours on trollies. This is completely inappropriate and sadly I’m not surprised at this horrific new phenomenon of ‘trolley deaths’. It’s high time our politicians came and listened to the concerns of healthcare workers rather than going on the airwaves to promote yet more misleading pledges. Our patience is wearing thin.”

It is nothing short of a disgrace that this situation is repeatedly occurring in the sixth richest world economy with no sign of positive change. It is sadly a predictable consequence of trying to run a health service with a gross shortage of both beds and the people to staff them.

Only proper planning together with funding that takes account of inflation and increasing need will improve this shameful state of affairs. The government must recognise that their funding commitment will not be enough to reverse this situation, and crucially they must take sole responsibility for the abject failure encapsulated by these damning statistics.

Dr John Puntis is a consultant paediatric gastroenterologist, the co-chair of Keep Our NHS Public, and a member of Doctors In Unite.

Coronavirus: how will an overstretched NHS cope?

Wuhan Novel Coronavirus (CoVid-19) has claimed over 1,300 lives and infected 60,000 worldwide so far, with no sign of slowing down. The NHS has become an increasingly fragmented service supplied by multiple providers, which is at risk of failing to deliver the co-ordinated, effective response that Coronavirus requires.

The last potential pandemic the NHS responded to was swine flu in 2009. Since then, the NHS has altered significantly – although privatisation was well under way, there were some notable differences that meant it was in a better position to respond to pandemic flu.

At the time there was a clear hierarchy from the top table decision makers: the Chief Medical Officer, Department of Health and the Health Secretary, down to the Primary Care Trusts and GPs. The Strategic Health Authorities operating above the PCTs had power to realign funding priorities between PCTs as needed.

An excellent report from the Centre for Health and Public Interest in 2014 reviewed the response in 2009 and found this hierarchy had a “clear line of sight,” allowing the co-ordinated response that swine flu required. There were flaws, such as a lack of evidence base for the widespread delivery, and the unnecessary stockpiling of anti-influenza medication, but in terms of interdepartmental communication and a joined up response, things worked well.

None of the organisations that existed then remain today, due to the top-down reorganisation that followed the Health and Social Care Act in 2012. We are now undergoing another costly reorganisation with the creation of Sustainability and Transformation Plans and Accountable Care Organisations. £79.9 billion of the NHS budget is controlled by Clinical Commissioning Groups, who purchase services from local providers. There is a fragmented landscape of different providers and disparate service provision across different regions. According to NHS England there are 150 independent providers of health services in England on top of the 233 NHS providers.

The Secretary of State for Health retains emergency powers to demand co-ordinated action, but these are yet to be exercised. It remains to be seen how these disparate services, with different contracts and arrangements, can be centrally directed to deal with a possible pandemic. We have lost the organisational memory that the swine flu response developed. With so many different providers with varying contractual arrangements offering widely differing health care services, an effective response to Coronavirus may be far more challenging.

Monitoring of the contracts with private providers is often poorly done, so it is conceivable that these arrangements might not be conducive to scaling up service provision in the event of a global health emergency. The chaotic healthcare architecture is exacerbated by the continuing cuts to local government public health services, as much as 8% from 2013 to 2018, and by our already overwhelmed emergency departments.

Coronavirus may well spread in large numbers. The neglect and fragmentation of our health service by the last 10 years of Conservative government could make a difficult situation catastrophically worse.

Dr Sammy Luney is a junior doctor and member of Doctors in Unite. A longer version of this article can be found on his Medium page.