From the West Midlands Socialist Health Association, April 2016

Towards a Manifesto for the NHS

There were two significant health events during March: on the 3^rd Shadow Health Secretary Heidi Alexander addressed a Labour Health Dinner in Birmingham (organised by WM Labour Finance & Industry Group), followed by Q&A with her and Philip Hunt (Labour’s Deputy Leader in the Lords, and former Health Minister). The discussion was continued at the WMSHA AGM on 19^th March, when Philip spoke at greater length about current events in the NHS. It was clear from what they both said that the NHS faces a crisis, exacerbated by the actions of the Conservative Government that took office in 2015.

Key issues from Heidi Alexander and Philip Hunt

On– very recently – taking up her role, Heidi’s three immediate concerns were NHS funding, workforce and the development of Labour Party policy on health and social care over the next 3-4 years. At the AGM, and in discussion on both occasions Philip Hunt and others raised, in addition, implications for Labour Party policy on the balance between resources and cost pressures, and the structural issues of devolution and integration of social care with health care. These are the headings for what follows:

Funding

Labour raised NHS from 6% GDP in 1997 to 8% by 2010. Osborne is trying to reduce total public sector to 1950s levels (37% of GDP), and NHS is slipping back towards 6% again.

The NHS is now well down the international league tables on both resources and performance: 24 OECD countries spend more as % of GDP (eg Germany 11%), and 20-30 have more modern medicines and equipment. The 95% 4 hour target for A&E has not been met for 6 years, and now stands at 86%.

The ‘extra £8bn’ negotiated by Simon Stevens has mostly been spent already to plug 2015/16 Trust deficits and the pension shortfall. The rest of his £30bn requirement depends on 3% pa ‘efficiency gains’ – levels never achieved before, and not achievable. Clinical Commissioning Groups are already rationing care to stay solvent. Acute Trusts will be £2.5bn overspent by end March – but at the same time Jeremy Hunt is requiring many to increase staffing. A Trust Finance Director has written to the Health Select Committee to say that Regulators are making Trusts disguise their real financial position.

The promise of ‘equal esteem’ for Mental Health has not been met. Present provision is very poor, especially for adolescents, storing up even greater future problems.

Alongside reducing real resources, cost pressures are increasing:

• Patients with multiple chronic conditions have increased from 1.9 to 2.9 milion since 2002, and the proportion of the population over 75 is also on an upward trend;
• Poverty has huge impacts on health, and inequalities are increasing;
• New medicines and technologies are seen as a cost not a benefit, even when giving better care;
• New medicines developed here are often not available to NHS: this is putting UK presence of US-based firms at risk.

The fall-out between Ian Duncan-Smith and George Osborne may be an opportunity to reopen resource issues, but demographic and cost pressures (above) mean there are no easy choices.

Workforce

The NHS has never been good at aligning training provision with its future staff needs. Ill thought out short-term changes have led to indefensible raids on trained staff from poorer countries and escalating agency costs. This has got even worse over the last 5 years:

Removal of student nurse bursaries, and nurses having to pay for their clinical experience as well as course fees and costs (which many mature students will be unable to do);

Professional development is being lost as a casualty of short-term, crisis driven decision-making;

Turnover of CEOs/managers prevents longer-term planning

The handling of Junior Doctors’ dispute continues to be disastrous:

• Cavalier overturning recommendations of independent pay reviews;
• Implying Junior Doctors don’t currently work week-ends is simply wrong;
• For a uniform 7-day week service consultant rotas would have to change more and the cost implications of that are unknown;
• The legacy of industrial unrest, poor morale and potential exodus are all escalating.

Integrating health and social care,

Sir John Oldham’s Health Commission provided a template for ‘whole person care’, but Health and Social Care are still differently priced and delivered. Councils cannot overspend, so must use assessments to ration Social Care to fit their budget. This means the NHS will be forced to spend more: whether by re-badging Health money or accepting the costs of delayed discharge.

Bringing Health and Social Care together requires us to tackle this basic problem, but already Social Care budgets are being raided to balance DoH books.

‘Sustainable Transformation Plans’ (cuts) are being required of Clinical Commissioning Groups. There are 44 CCG consortia in England, but these do not relate to Council boundaries or roles.

Prevention of ill-health through Public Health action is essential to the long-term sustainability of the NHS, but budgets have already been cut (£200m cut this year, £300m next).

Devolution

Devolution could improve efficiency (eg early years education that focuses on future health), but:

• Councils must ration to stay within budgets while the NHS is demand-led: so one or both must change, meaning structural changes would be needed in parallel;
• There are not enough councillors who understand health issues, so Combined Authority leadership will be crucial;
• There is a risk of devolution being a device for Government to blame Councils for NHS failures;

The link between the healthcare sector of the local economy and innovation in the NHS could be strengthened with benefits to both, but the Innovation hub infrastructure has been run down and needs regeneration (in Manchester it is in better shape).

IT could be key to changing relationships, but would require an approach that fostered participation, trust and enthusiasm rather than imposition, suspicion and resistance. The bottom-up strategy successfully pioneered by Bologna perhaps offers lessons.

Developing Labour Policy

(a) Process

Heidi expressed her intention listen to those with expertise over the next 3-4 years while policy is being developed (communications by e-mail to her or her assistant, Tom Witney). Pointers that should guide the process include:

1. The present Government piles on demands, but without accepting the associated costs. Under Labour the NHS needs to take fiscal responsibility, so there must be room for manoeuvre between headings: setting priorities means some expenditure headings may need to be reduced.
2. Looking forward, money is the big issue. We can’t accept Government story that NHS expenditure must be reduced, but the public appetite for more taxation is limited. Labour must have a credible story on how it will meet costs, so other funding sources may have to be considered.
3. The perpetual imbalance between acute medicine (urgent, politically sexy) and prevention (non-urgent, unsexy but important), needs to be recognised as a political, not technical question. The notion of a ‘Non-political NHS’ is a pipe dream. The Labour Party must lead on what NHS should look like and how it should be paid for.
4. Labour MPs want less privatisation, and no-one wants more top-down reorganisation, but dismantling the present system is a substantial restructuring in itself;
5. At present managers are not in control – consultants are, and this may need to change;
6. PFI costs not huge in context of NHS overall – may be waste of time/money to undo?
7. Competition law still exists but tendering is no longer favoured by NHSE (a powerful disincentive);
8. Should not be panicked as private interest already tempered by lack of room to make profits;
9. However, TTIP remains a real threat (though an isolationist US may be less keen to sign?)

Current private members bills seeking to return NHS to its roots may pre-empt necessary debates about structures, funding and priorities, especially if treated as ‘loyalty test’ (SHA Central Council has yet to consider).

Real workforce planning is crucial to institutional stability and longer-term financial sustainability.

(b) Next steps

At the AGM we agreed that the issues arising from the presentation and subsequent discussion should be circulated preparatory to holding a West Midlands Health Conference in the autumn. We also noted that a national SHA policy conference is to be held in Birmingham on 18 June, providing both a milestone and further opportunity for our input.

Alan Wenban-Smith