Five political decisions that drove the NHS to the brink
NHS wait lists are bursting at the seams. From austerity to privatising social care, this is how we got here
Rishi Sunak was once again forced to deny that the NHS is facing a crisis this weekend, claiming that the service is merely “under pressure”.
The prime minister has continued to face questions about the state of the health service following increasingly dire warnings from health officials and record-breaking delays.
Close to one in four ambulance patients in England waited more than an hour in ambulances queued outside hospitals before being admitted to A&E in December. Last week Adrian Boyle, president of the Royal College of Emergency Medicine, warned that between 300 and 500 people are dying each week as a consequence of delays in urgent and emergency care.
The pressures are not limited to emergency care: 7.21 million people are now waiting for NHS treatment in England, including 410,983 who have waited more than a year for treatments that should take a maximum of 18 weeks.
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Health secretary Steve Barclay has blamed high flu and Covid cases and fears over Strep A outbreaks for the current crisis. But health experts have told openDemocracy that multiple political decisions made largely under the current Conservative government – but also by Labour prior to 2010 – have brought the health service close to collapse.
The legacy of austerity
In October 2010, then chancellor George Osborne announced the biggest package of cuts since the Second World War, totalling £81bn. Speaking at the time, he justified austerity as necessary to put public services “on a sustainable footing”.
Although the NHS was spared from this first round of cuts, its funding nevertheless fell significantly. The health service received just 0.1% real-terms increases to its funding each year until 2015 – far short of the 4% real-terms rises it had averaged annually since it was established and the 6% it averaged under the previous Labour government.
At the time, the King’s Trust health think tank said the NHS was facing the “biggest financial challenge in its history” and warned that the 0.1% settlement would “not be enough to meet increasing cost pressures or cope with increasing demand for services from an ageing population”.
From 2016 onwards, the Conservative government increased the NHS budget by 1.6% a year. In 2018, then prime minister Theresa May announced that the NHS would receive an average 3.4% increase in its budget each year until 2023, as a “birthday present” to mark the 70th birthday of the NHS. But by then, the gap between the health service’s budget and what it would have had if the average 4% increase had been maintained since 2010, had grown to £42.2bn, according to analysis by the British Medical Association.
Boris Johnson announced a further uplift in 2021, setting real-terms annual spending increases at 3.9% a year until 2025. By now, the funding gap stood at £50bn. Although the move put funding increases back in line with the historical average, the “new plans allow for little or no long-term additional costs as a result of the pandemic”, according to the Institute of Fiscal Studies.
Between 2009-10 and 2019-20, NHS spending had grown at an average real-terms rate of 1.6% per year – lower than any previous decade in NHS history.
“You can see the cumulative impact of that when you [compare] England to comparable countries,” said John Lister, a long-time health campaigner and co-author of ‘NHS under siege’.
“We now have fewer beds per head, fewer doctors per head, fewer nurses per head and we’ve got a £10bn-plus backlog of maintenance for hospitals.”
Failed efficiency savings
Faced with a significant drop in funding and rising demand for services, successive NHS chiefs have sought to cut costs since 2010.
Although health ministers have long attempted to drive up productivity in the health service, now NHS bosses were being tasked with making more than £40bn of savings by 2020 just to keep the service afloat.
“That really framed the way the NHS was organised on the ground. It led to the development of ‘sustainability and transformation plans’, which, in essence, sought to reduce hospital capacity and move care out of hospitals and into the community and into different kinds of care settings,” said David Rowland, director of the Centre for Health and the Public Interest.
Health experts and hospital doctors told openDemocracy that the cost-cutting plans have not only resulted in the loss of vital services and rising hospital deficits – they’ve failed to close the funding gap.
Julia Patterson, who worked as a NHS doctor between 2010 and 2018 and later founded the campaign group EveryDoctor, experienced first-hand how cost-cutting led to mental health services for children and adolescents being scaled back.
“A lot of the specialist staff were being lost. So an effective team might involve an art therapist and multiple psychotherapists and psychologists and what we were finding is that a lot of those additional staff who have specialist experience were being let go. And once they left their jobs, they weren’t being recruited again,” Patterson said.
And she warned: “Back then, our concerns were that we were losing our ability to deliver holistic care to people. In recent years, it’s been more about people dying because we can no longer provide even basic care.”
Brexit and the pandemic
The NHS entered the Covid pandemic already facing multiple pressures. It had 39,000 nursing vacancies in England and fewer doctors, hospital beds and CT scanners per person than in many similar countries.
Staff had endured years of pay cuts: average pay for consultants in 2021 was 9% lower in real terms than it had been in 2011, 4% lower for junior doctors and 5% lower for nurses.
While lockdown restrictions have been lifted, hospital activity has remained high throughout 2022.
Rowland disagrees with the health minister’s view that the crisis is largely due to the pandemic, but does believe it is an important factor.
“We are failing to acknowledge the fact that the pandemic isn’t over... And now we have a workforce that is exhausted and under capacity,” he said.
Brexit has also played a role in the crisis by exacerbating staffing shortages. After the referendum, the number of European doctors entering the health service slumped. If pre-Brexit recruitment trends had continued, the Nuffield Trust estimates that there would have been 4,000 more doctors – enough to fill nearly half the 9,000 vacancies.
Several of the experts who spoke to openDemocracy pointed to the increasing involvement of the private sector in the NHS as one of the factors that led to the current crisis.
Colin Leys, a retired professor in political economy and co-author of ‘The Plot Against the NHS’, believes that NHS reforms in 2002 under the then Labour prime minister Tony Blair were a significant milestone.
“It introduced, among other things, the idea of private provision of clinical services,” he said. “Ever since then, there’s been a perverse incentive to shift care towards the private sector.
“For example, it was easier for hospitals that were short of capital spending – which they all were through the post-2008 period – to get their own doctors to go and do a backlog of operations in a private hospital down the road at public expense than to provide the facilities themselves,” he said.
The result was that funding provided to the NHS went towards the profit margins of private providers, rather than being invested in improving the service.
Successive governments have entrenched the health service’s reliance on the private sector, according to Allyson Pollock, a clinical professor of public health at Newcastle University and author of the book ‘NHS Plc: The Privatisation of Our Health Care’.
“It’s nonsense to say it’s all down to George Osborne,” she said. “Each successive administration since the 1990s bears responsibility for the crisis.
“Under New Labour, there was a big period of privatisation through private finance initiatives [PFI].” Through PFI, Labour oversaw the expansion of the private sector’s role in building new public infrastructure such as hospitals and schools, and then charging it back to the public purse with interest over a period of years or even decades. The practice was originally introduced under Tory PM John Major in 1992.
Pollock also points to reforms in 2012 under former Conservative health secretary Andrew Lansley that she says further opened up the NHS to the private sector under the guise of increasing competition.
Some campaigners disagree, however, that privatisation is largely to blame for the current crisis.
“The NHS spends at most about 25% of its budget on private providers,” said Lister. “I think all of us on the left would rather that hadn’t happened. But actually, the question is: ‘Is there enough money in that 75% – and in the other 25% – to ensure that there’s sufficient capacity in the NHS?’
“And the reality is that there isn’t – that’s the underlying problem.”
Passing the buck on social care
At its most basic level, the current crisis is a result of a lack of available hospital beds. But as senior paramedic Glenn Carrington explains, there are a number of factors at play behind this shortage.
“The hospital works in a circular flow,” he said. “You interrupt any of that flow and you’ve got trouble.
“OK, so we rock up in our ambulance. We put the patient in through the front door – then the patient goes up to the ward, gets treated, and goes out into the community.
“But hang on – they can’t go into the community if there’s no nurses to look after them there. So that means they can’t take them out of the beds in the ward. If there’s no beds you can’t take patients from A&E up to the wards. So we turn up and we can’t offload.”
In other words, a failure to address problems in one part of the UK’s healthcare system – in this case, social care – can have a disastrous knock on effect.
Lister agrees and blames successive governments for passing the buck on fixing the social care system for decades, leaving it now facing a record 165,000 vacancies.
“The social care system was partly privatised in the early 1990s as part of the [Major government’s] determination to ditch the commitment to long-term care for older people and inflict means-tested charges on them.
“Since then we’ve had a system that is completely dysfunctional. Successive governments have said it’s a mess but failed to sort it out. For example, Labour had a Royal Commission in 1999 and decided to ignore its recommendation to provide universal social care because they weren’t prepared to spend the money on it.” (The government said at the time that free social care would not necessarily improve services or help the poorest people.)
A third of care homes are now operated by large-corporate providers some of which are owned private-equity firms who are “managing to extract huge profits out of what appears to be a loss-making service,” Lister said.
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