I would like to bring your attention to a severe and debilitating case of austeritis in a 67 year-old institution.
The patient, NHS, presented on several occasions over the last five years with symptoms of an immune-mediated (1) haemorrhagic disease affecting its many hospitals, clinics and care centres. Although our initial understanding of the condition was scanty the pathogenesis of the disease is now clear, pointing to some potentially effective treatments for a cure.
1. Government killer T cells and senior health macrophages attack the body’s own funding
Government killer T cells (2) attack the body’s overall funding supply, misguided by a mutated ideological antigen (Austerity+) appearing on the surface of the body’s central institutions.
Inappropriately stimulated senior health management macrophages (3) have been similarly destroying funding streams by a process of phagocytosis (i.e. ingestion). The macrophages, a potential defence of the body’s system, demonstrate an inability to scrutinise the dubious claims of Austerity+ - that cuts are necessary to reduce a bloated public expenditure in an over-indebted economy.
A critical aspect of the cure will involve equipping the body’s own defence system with the means to recognise the dubious claims of the ideological antigen. Consider these graphs looking at total government debt as a proportion of GDP and total government spending. Notice firstly that we are not more indebted than we’ve ever been and that we’re not spending more than we’ve ever spent. Notice also that one of the most precipitous and sustained reductions in the level of public debt occurred during the post-war ‘golden years’ which simultaneously saw a persistent increase in levels of public spending.
Austerity+ is misleading macrophages: the damage to the NHS and the risk to patients that will result cannot be justified in simple economic terms.
2. The body haemorrhages resources (not through staffing its hospitals)
The haemorrhaging of public resources is occurring at a number of sites. Tampering with the blood supply to the vital organs of staff running services is not a way to tackle this haemorrhage.
The principle sources of haemorrhage are:
a. Individual trusts have taken out unmanageable and extortionate private debt.
A study by Shaoul et al. in 2008 found that 12 NHS hospitals had taken out private sector debts costing them £60M a year, which was 20-25% of their incomes at that time. Given that the debts are linked to inflation, while hospital budgets are not, this is now likely to be considerably higher. Pollock and Price have linked these debts directly to drives for service closures and bed and staff reductions.
b. The internal market in the NHS – the split between funders and providers – results in unnecessary and expensive administrative and bureaucratic costs
In theory, commissioning health services should save money. Funders outline the services they need and healthcare providers bid to offer the best ‘value for money’. However, the process involves high legal costs and considerable unnecessary bureaucracy. The 2010 Health Select Committee found that running the NHS as a market cost it 14% of its budget each year (a figure calculated even before the fresh impetus to tender contracts in the wake of the 2012 Health and Social Care Act). There are inevitable administrative tasks in any organisation, but the pre-market late-1980s NHS spent only 5% on administrative costs. A conservatively estimated £4.5 billion a year could be saved through abolishing the internal market and reuniting the managers of NHS finances and providers of NHS services.
c. Pharmaceutical companies profit from public expenditure, making between 20% and 40% profit on medicines sold to the NHS
An estimated £6-7 billion of NHS money is siphoned off into pharmaceutical profits each year. The NHS has considerable leverage as a major purchaser of medications to negotiate lower prices for pharmaceuticals and to fund the research and development of new medicines. In spite of this, drug spending has been increasing year on year with a rise of 7.6% in expenditure in 2013/14 from the previous year.
3. The disease manifests throughout the body, restricting the stream of funding to the vital organs of staff running services. The result will be multiple organ failure.
The combined attack on overall funding and the haemorrhage of resources from the NHS will eventually result in the failure of the vital organs of individual health services, with multiple organ failure compromising the patient’s chances of survival.
It is inevitable that further cuts will result in staff and service reductions. The Francis Inquiry highlighted the role of imposed year on year reductions in spending on the ability of Mid Staffordshire NHS Foundation Trust “to deliver a safe and effective service” (Report of the Mid Staffordshire NHS Foundation Trust: Executive Summary, p45). It also emphasized the “unacceptable delay in addressing the issue of shortage of skilled nursing staff” (Ibid). In spite of attempts to water down recommendations about minimal levels of skilled staff and to delay or suppress research by NICE into safe nurse staffing levels, underfunded and overstretched health services nevertheless cost patient safety and ultimately patient lives.
The problem facing some senior health macrophages appears not to be a lack of recognition of the dubious claims of Austerity+ so much as impotence to effectively contain it. Whilst leading medical, care and local authority organisations have spoken out against the damaging impact of cuts to public health services, there has been a failure across the broader health service to speak out and to put up a fight against this debilitating disease. Protests and potential strike action over the junior doctors’ contract signal a change in the tide among health professionals and perhaps the beginnings of effective immune resistance.
In an attempt to stem on-going haemorrhage, the NHS Reinstatement Bill will have its second reading in the House of Commons on 11 March 2016. The bill aims to reverse damaging market reforms and renegotiate and potentially centralise the debt of individual trusts. As health workers campaign against the attempted imposition of an unfair and unsafe contract on junior doctors, it will be critical to link the struggle for decent wages and working conditions to this deep-seated condition that has taken a hold of the vital organs of the health service. To put up an effective immune response, we must come together as healthcare workers and be clear of the pathogenesis of the disorder if we are to ensure successful resuscitation of the NHS.
(1) A disease caused by attack of the body’s protective system, the immune system
(2) A type of cell that stimulates an immune response. If stimulated inappropriately, the immune system can cause harm.
(3) A type of cell involved in an immune response. These cells ingest and destroy dead, dying and infected cells and debris by a process called phagocytosis.
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