For many years there have been local campaigns against closures and reconfigurations, some of which have had success. Lewisham and Stafford both spring to mind – very different campaigns but both with huge widely based local support. Trade unions have often led successful campaigns against changes such as outsourcing of services or the spectacularly futile attempt to privatise the management of George Eliot. A reasonable question is how can there be some scaling up of the local approach into some kind of national campaign – with what aims?
Getting a broad campaign to Kill the Bill was relatively easy. It’s also easy to campaign to save XYZ Hospital or a GP surgery or even a foot clinic which is easily recognisable. A ‘national’ campaign to Save our NHS is a great deal harder. Agreement on what should be the overall policy as regards health and care is harder still.
Nobody should denigrate the value of local campaigns which directly confront and challenge changes that harm services, but most accept that ‘saving’ the NHS requires something more, mostly a change in government and that poses different challenges to organising a local march or petition.
But in terms of building a national campaign it is no longer sensible to campaign to save the NHS (or even to reinstate the NHS). The issues are much broader and no solution for the NHS without a solution for social care is even worth thinking about.
We should be campaigning about how we can and must stop the well evidenced deterioration in care services as a result of austerity and government policy. Hundreds of thousands are being denied the social care they used to be entitled to; cuts in social benefits have meant misery for many families as well as mental health problems rising dramatically; hundreds of thousands are having their health compromised by inadequate housing; funding for Public Health has been arbitrarily cut.
At the heart of any campaigning must be reasoned but determined opposition to austerity with the inevitable growing inequality and injustice that it brings. The care system we all want to see is founded on the opposite of neo-liberal principles. We support the value of public services both economic and social and we value the key role of good care services in the fight to combat rising inequality. A universal, comprehensive, free service paid for out of general taxation with a major core of services provided by public bodies is a key part of any model for social justice. It also appears to be highly efficient and cost effective.
Social care is already a national disgrace and funding cuts have to be reversed. In itself this causes major knock on problems for the NHS. Community care is also under attack and vulnerable to privatisation. The biggest threat to quality care now is inadequate funding, a consequence of austerity – a political choice. For the NHS there is a growing likelihood of some kind of real crisis early next year – with queues of ambulances, cancelled operations, growing waiting lists, and even closures of parts of some NHS organisations.
If we wish to maintain the ‘free’ NHS and the provision of means tested social care in its current form, and also to achieve and then maintain reasonable standards of care then public funding has to increase – and increase a lot. This is without looking at how we reverse iniquitous changes in the social security budgets and the appalling housing crisis.
But we already have ‘promises’ that add still more cost; 24/7, more GPs, major pay and conditions improvements for care staff, more funding for mental health, shorter waits for some diagnostic tests and probably more. Or indeed universal free social care.
So unless we accept that by 2020 public funding for the care system will increase (probably by around £25 – £30bn) we have to accept further detrimental changes in our services. Even the notable Kings Fund agrees! The government cannot have cake and eat it – the bakers have already eaten it. If we want to make the changes to a better, even a more effective system, then that will take considerable short term investment and the think tanks are openly talking of funding of £1.5 – £2bn per year for 5 years to make changes possible.
The core of any campaign is about increasing funding by increasing taxation – not usually popular. We have to get over that ideas that £billions can be saved by various daft schemes and reorganisations are fanciful. Continuing with pay restraint and attacks on terms and conditions can’t work. Efficiency in social care has meant a race to the bottom and poor care as a result. Real productivity gains could be made by working with staff but not by alienating them. The NHS may be poor at many things that could be improved and save money but not at the kind of scale that magically releases £billions any time soon.
We have to campaign to convince the electors that the current care system is no longer improving but actually getting worse with many people suffering more than is necessary; the evidence is out there. The choice is between a deteriorating service with the likelihood of charges and top up payments or something better and improving in the way it improved in the decade before the bakers crashed the economy. This is not actually very demanding as the increases needed in terms of %GDP would only see us back in our rightful place alongside the other major European states with comprehensive care systems.
Our initial problem is that the public appear to think the NHS is glorious but inefficient with little common sense applied and also that it is overwhelmed by increased demands from immigrants.
The next major issue that campaigners have to face is about the way care provision has to change and how accountability should be established. Something we have to have answers about like the finances. This structural stuff hardly excites the electors. Campaigning against TTIP, against PFI, against privatisation, against Foundation Trusts, against Serco, against small business GPs and so on may be necessary but actually the evidence is that it has little or no impact on voters.
Currently there are numerous significant changes actually underway – with devolution, with Vanguards, with ‘success’ regimes, Better Care Fund, and endless schemes around pooled budgets and other steps to ‘integrate’ services. Alongside this trend we are also seeing services being taken back into public control and private providers walking away from any interest in clinical services – an obvious consequence of there being no money. Amusingly almost all of these schemes are undertaken by ignoring the H&SC Act we all fought so hard to kill off.
But over the next 5 years big changes will have already happened so we do need to have a position around the issues of accountability. We have to be able to make the issue into something voters might have at least some interest in. Voters appear to like democracy so one line of argument might be greater transparency over who is making decisions about how care priorities are set and how funding is allocated and how they can be held to account through the ballot box. But the whole idea of genuine accountability is so alien to the NHS that this is really a big issue for a wider care system approach. The really big point is who decides how the money is allocated who is accountable for problems if the cause is the inadequate funding that was allocated to some devolved authority?
We also need to be clear about just what decision making can be devolved and what stays national; with staff terms and conditions and safety standards clearly being examples of national.
And the maybe we need clarity about our own rights and roles. How do we establish more shared decision making? How do we give communities a greater say? How can we ensure we have full access to all the information that is used by decision makers? And my own favourite how do we plan for the workforce that will be needed locally, (regionally) and nationally – as currently it’s an expensive mess.
Anyway a campaign has to show how much better our care system can and should be. It must be able to address the major themes:-
- The end of austerity and the need for much greater public funding of the care system which mostly actually translates into more and better equipped staff.
- The removal of the barriers that prevent care being properly joined up (including, but not merely, competition and markets).
- The need for policy to be driven by understanding the social determinants of poor health and so
- The need to stop looking at the NHS in isolation and to look across the whole of care – even extending into housing.
- The need for real democratic decision making and also for other forms of participation and involvement supported by full transparency.
Do we want a better care system or will we sit back and watch as the system we have just gets progressively worse? If we can paint the picture of what deteriorating public services really means for millions of real people then we are in with a chance.