Daily Mail and David Cameron launch Health Hero Awards with picture of Cameron's late son
"So many of us have been there. You're in the waiting room as your child goes into the operating theatre. The minutes feel like hours, and the hours go on forever. As you wait for news, a nurse comes to put your mind at rest, reassuring you that your child is in the best possible hands. And in that moment you feel overwhelming gratitude towards our National Health Service."
That's David Cameron in the Daily Mail last week, launching this year’s campaign to honour health care workers, our "angels in aprons" and "superstars in scrubs". As before, Cameron uses his personal story — his late son Ivan suffered multiple disabilities — to reassure the British public that the National Health Service is safe in his hands. Yet, at the same time, the coalition government has enacted a series of changes that undermine the NHS’s very existence.
In Britain today, people can visit their family doctor or their local Accident and Emergency Unit if they are in need of medical help or advice. There is no charge. This was one of the founding principles of the National Health Service and is an achievement to be proud of. The amount of healthcare available is usually determined by an assessment of the needs of a particular population of people. However a number of recent changes to the way the NHS is run mean that in the future a hospital’s financial status will be the most important factor when determining what health services are available.
The Care Bill is likely to become law next month. Although there are last minute attempts to modify it, it is likely to include a Clause - 118 - which will give new powers to close hospitals regardless of local wishes. The Clause means that if a hospital is getting into financial trouble, the government can send in “special administrators” to rapidly close or downgrade services with little consultation - not just in that hospital, but at others in the local area, even if they are popular and performing well.
As the money now follows the patient through a payment by results system (which is really a payment by activity), forcing patients to attend a “failing” hospital increases that hospital’s income. In support of this measure the Health Secretary Jeremy Hunt talked of improving “failing hospitals”. However he does not mean hospitals that are proving insufficient or inadequate care, but instead he means hospitals that have not made their books balance.
Hospitals across England and Wales are suffering from a double lock of financial hardship – while the government cuts their budgets, payments for new hospital buildings continue to increase, squeezing the amount they can spend on patient care. Millions of people across east London rely on Barts Health NHS Trust to provide their healthcare across 5 hospital sites. However, the trust is currently in a financial rescue situation as at one point last year it was losing £2 million per week. While the government demands brutal “efficiency savings” from the Trust, the payments it makes as part of its £1.1 billion Private Finance Initiative contract have increased from £115 million per year to £129 million – a whole 15 per cent of its entire budget.
When funding becomes this tight the first move from most Boards is try and reduce hospitals’ biggest expenditure — staffing levels. As part of a staffing review last year Barts Health removed or down-banded 600 nursing posts and hundreds more administrative staff. This has the effect of increasing the workload for the remaining staff, weakening morale and increasing stress, which inevitably leads to a poorer quality of care for patients. As permanent staff leave, the gaps are plugged by agency staff who are less likely to know the hospital well and often require more time for tasks. More time is spent booking and chasing staffing agencies and further increasing overall staffing costs.
This exact scenario happened at South London NHS Trust in 2012. In response to financial difficulties at the trust the government sent in administrators who recommended that the A&E department of a neighbouring hospital at Lewisham be closed. The idea behind this is that more patients would then travel to South London NHS Trust hospitals; since a hospital gets paid for “patient activity”, this would increase its income and reduce the financial problems it was facing. There were no problems with the financial status or quality of care provided at Lewisham and this was not a decision made by clinicians based on population need, but instead a decision made by accountants to balance the books.
Understandably there was huge public outrage and protests at this decision. The Campaign to Save Lewisham Hospital eventually took the government to court and won their case that closing a well performing hospital was not lawful and Lewisham A&E remains open today.
However, the next time a local community get this kind of treatment from the government they will have no way of fighting back. Clause 118 means that administrators now have the power to close health services in the vicinity of a hospital that is facing financial difficulty.
You may think that it would be the Health Secretary's responsibility to protect a good hospital. Yet, amongst the vast chaos of the 2012 Health and Social Care Act, a small clause was changed that radically altered their responsibilities.
The Health Secretary used to be required to “provide or secure” a comprehensive health service, but now only has to “promote” one. While this may seem like a small change in language, it completely alters the legal framework in which the government works to provide healthcare across the UK. In its simplest form this largely requires Jeremy Hunt to say that the NHS is a good idea. Ultimately this strengthens the role of finance consideration in determining health service provision and removing the responsibility of the Health Secretary to ensure that all people can access healthcare equally.
Many NHS staff have been watching this happen in horror and protesting over the past 4 years. Angry doctors and nurses have protested outside parliament in the rain and the snow, and 50,000 people took part in a parade in support of the NHS at the Conservative party conference last year. Tony Benn once said “… there are two ways in which people are controlled. First of all frighten people and secondly, demoralise them”. The hard-working "angels in aprons" and "superstars in scrubs" have suffered both, through the annual real-terms cuts in pay and large-scale service reconfiguration and redundancies. Fewer staff now have the energy or motivation to speak out.
Part of the challenge is that technical changes like Clause 118 do not capture people’s imagination. While people can still visit their GP and local A&E free at the point of need the NHS’s underlying legal status may remain only a distant concern. However, if we see another Conservative-led government after the next election, there will certainly be a more aggressive programme of hospital closures to trim the size of the NHS. Undoubtedly, as finance becomes the primary way of determining health need, people will begin to be asked to pay when accessing hospital services. By this point however, it may be too late to protest.