A healthy economy depends on a healthy nation. Time to break the austerity myth. Time to unravel the truth.

Whilst the Brexit train crash rumbles on and distracts the nation, the ongoing economic and social instability caused by cuts to public spending and the pursuit of ideologically driven policies by the current government is inevitably coming to a head. The NHS has borne the brunt of cuts which have left it struggling to provide adequate services.  Along with pay cuts, job losses and hospital and GP surgery closures, there is an on-going exodus from the profession due to stress and overwork.  But together and in addition to these devastating cuts, the NHS has also been undergoing sweeping reforms, largely out of the public eye, that have been designed to fragment it and ultimately turn it into a system of private/ public partnerships where public money simply becomes a cash cow for private profit. The public has been told there is no alternative, as the health service is no longer affordable or fit for purpose, and that drastic reform is the only thing that will save it.  The evidence is now piling up about the consequences of both the cuts to service provision and the extensive reforms which are forging ahead under the guidance of NHS England behind closed doors and with very little parliamentary or public scrutiny.

The Times this week reported that patients up and down the country in a post code lottery were being denied cataract, hip, knee and hernia operations as a part of an NHS cost cutting exercise justified by the erroneous claim that such interventions were of little or no value (unless of course, you happen to be the poor patient in pain or with failing sight being denied help). There are ‘hard choices’ to be made said the body representing Clinical Commissioning Groups, with ‘competing priorities’ and a ‘lack of cash’.

This was followed in the same week by an article in the Guardian which reported that following an unexpected uptake of cervical smear tests the system was at breaking point and unable to cope with the increased demand. This was swiftly followed by the announcement that the private company Capita is to be stripped of its cervical screening contract because of its failure to deliver an efficient administrative service putting women’s lives at risk. The same week The Independent in their article on the NHS trial of Home Cervical Screening for some parts of England, their summary of this trial includes the details of private companies already marketing home cervical testing kits in the UK, and asking women to take the results to their local surgery to discuss the results with their GP. This is a worrying development. For decades women have been encouraged to attend Well-Woman clinics at their registered surgery to discuss a myriad of health issues, including blood pressure, weight, blood sugar and general well-being. For many women their five-yearly road-check is their only contact with their GP and where the continuity of care central to the NHS is developed.

Earlier this month, the media reported (with great fanfare) that NHS England was calling for the Government to scrap the laws driving privatisation of the health service (but not for a real change of heart about private involvement we hasten to add). But shortly afterwards, it contradicted its proposals and awarded the cancer scanning services at Oxford University Hospitals to a private company InHealth even though the OUH has an international reputation for its cancer care services.

And, as if that weren’t enough of an indictment of government austerity policies, cuts to spending and reforms which have decimated the NHS and left a trail of destruction, its outsourcing programme (although not a new phenomenon and not confined to the Tories) is coming off the rails.

Following the collapse of Carillion in January 2018, Interserve (which also delivers public services and PFI and hospital contracts across the country) is also in a financial fix. Contracts worth billions of pounds of public money for NHS and community care services, prison security and probation, have been sunk into private provision and its associated profit. Even when it seemed the game was up, ministers continued to award them profitable public contracts at the public expense, in terms of shoddy and incompetent service delivery. And all the while their Executives carried on creaming off public money in high salaries and dividends. A nice little earner for some.

Are the wheels coming off the neoliberal wagon? One would like to think so, but the truth is that the 40-year old plan to dismantle the NHS is still going full steam ahead with no sign of slowing.

Whilst the Tories speak in glowing terms about their policy priorities from health campaigns to mental health, talk about maintaining a ‘free at the point of delivery’ service and even about their generosity in extra funding for the NHS, (which is risible considering the cuts over the last 8 years and that the promised £20.5 billion extra over 5 years will do nothing more than stabilise the service), behind the politicians’ pretty words lie something much more insidious. Successive Chancellors since 2010 have justified their cuts on the back of a lie; the lie that the state finances were like a household budget and that tax or borrowing constrained government spending on public services. The lie (which they are perfectly aware of) that cuts to public spending were essential to reach the nirvana of balanced accounts and show that, unlike Labour, they were fiscally prudent.  In a game of smoke and mirrors, it has allowed them to claim that there is no alternative to a pared down NHS that lives within its financial means and that service delivery would be carried out more efficiently by the private healthcare sector (despite growing evidence that that is not the case). Of course, it goes without saying that the money is always found when needed to win votes or keep rich people sweet.

Under that smoke and mirrors cover the on-going privatisation of the NHS has gone largely unnoticed by the public. Public ignorance has allowed the government to deliver an ideological agenda on the back of the lie of unaffordability and balanced budgets. The NHS has been at the receiving end of that agenda and although the public are seeing, indeed experiencing, the consequences of spending cuts to the NHS, they are less convinced or indeed worried that it is being privatised. Because people see the NHS logo they still think we have a National Health Service. We don’t.  Our NHS is now a fragmented organisation in which private sector companies deliver services behind a now ‘global’ NHS brand to make profit at the expense of patients. Where US companies are providing back office services waiting patiently for the real business opportunities to be realised.

The concept of Integrated Care has a nice ring to it and is designed to take the focus away from Accountable Care systems, US style.  It is being sold to an unwitting public by unprincipled health service leaders at the top of the chain of command as a solution to the crisis in health and social care. It is now being delivered by many credulous NHS foot soldiers further down the chain on the basis that there is no money and no alternative given the government’s objective to get the NHS’s finances under control.  The Five Year Forward Plan which has now morphed into the Ten-Year Plan will be the vehicle for implementing even more far-reaching changes to the NHS to create a new centralised structure of 44 Integrated Care Systems by next month. As analysis by the campaigning group Keep Our NHS Public shows it will lead to the break-up of primary care and force mergers of GP practices into large multi-speciality hubs, increase the use of private hospitals to deliver NHS funded care, enforce further fire sales of NHS estate, introduce hard financial targets to force compliance and increase reliance on private digital providers. Furthermore, and worryingly KONP points out that ‘none of these new structures will be in any way accountable to local people and communities they cover’.

As mentioned earlier in this blog, there was much clapping and sighs of relief at proposals by NHS England to repeal the key parts of the Health and Social Care Act 2012 that forced CCGs to put contracts out to competitive tender, which led predictably to a huge expansion of private sector involvement in NHS service provision and is, like the internal market purchaser/provider split, very costly to operate.

According to Simon Stevens, these provisions are hampering the drive to provide better care through service integration and he would like to see them replaced with a ‘best value’ test instead. If it was intended to soothe people’s concerns about where the NHS was going, then it did its job including for some on the Labour benches. All but the most savvy of campaigners have welcomed these proposals. The stark reality is that there is nothing to prevent Integrated Provider Contracts being awarded to the private sector or indeed sub-contracted. NHS England’s 10-year plan is but the next step in a 40-year old process in which both Labour, Conservative and Coalition governments have sought to undo the achievements of the post war consensus which led to the setting up of the NHS and the welfare state to serve citizens and drive economic and social well-being.

There are many people who think it does not matter who delivers the NHS, as long as it remains free at the point of delivery. They may not recognise it, but they are saying, in effect, that they have no problem with public services being run for profit with all that that means as long as their access is not restricted.

But what if the public knew what these changes really mean in a cash strapped environment in which whole population, capitated budgets are being sold to us as a better way to manage services and use deliberately and unnecessarily limited financial resources?

What if they knew that it will put financial considerations ahead of patients’ clinical needs and that decisions will be made based on financial affordability and not the interests of sick patients?   Rationing is already happening from hips to knees to cataracts and hernias which is where this blog began and many previously provided services are no longer available on the NHS. Who knows where this will end? Our health subordinated to finance.

What if they knew that a reformed and poorly funded NHS which has had to ration its clinical treatments will open the door to private health insurance and provision for those that can afford it?

What if, in reality, we are heading for a two-tier system of haves and have nots? People who are not yet a captive audience to the health insurance industry but who can afford to pay may not recognise the dangers. What they fail to understand is that insurance is about determining risk not caring about people in need, as US citizens well know.

What if they fail to understand that their lives and the lives of their families and friends depend on access to a publicly paid for and delivered health service?  The lack of which US citizens have discovered to their cost, both in money and health terms

So, when the government tells us that the NHS is unaffordable and that we must cut our cloth (meaning that public services are only sustainable based on tax revenues or that borrowing too much to service unsustainable public provision will leave future generations with a huge debt burden), it is time to challenge the orthodox narrative that says there is no alternative.  A healthy economy does not depend on tax revenues, it depends on a healthy nation. The only constraint any government will face when deciding its priorities are the resources themselves.  Do we have enough doctors, nurses, hospitals and equipment to provide a good service? And if not why not?  At the end of the day, that always relates to the political or ideological choices that governments make and where as a result it chooses to spend public money.

Arnold Toynbee wrote:

“The twentieth century will be remembered chiefly… as an age in which human society dared to think of health of the whole human race as a practical objective”

Let’s hope we don’t forget that in the 21^st.