The Tories’ dismemberment of the NHS in England can be seen as the apotheosis of their austerian agenda, for it embodies in a single sweeping strategy their party’s animating instincts: namely the drive to privatise public services — no matter how cherished — and the compulsion to inflict gratuitous pain and suffering on the most vulnerable in society.
So desperate is the plight of our health service that the chief executive of the British Red Cross was moved to state at the start of this year that it was facing a ‘humanitarian crisis’. In light of research that has linked 30,000 excess deaths in England and Wales in 2015-6 alone to savage cuts to health and social care, it would be unwise to join Theresa May and Jeremy Hunt in dismissing as hyperbolic the BRC’s assessment of the situation.
Had we but space enough and time, Tory malfeasance in relation to the NHS could be set out in something like its fullness. But let us limit ourselves to some of the starkest depredations of the past seven years. According to The King’s Fund, we are midway through the ‘largest sustained fall in NHS spending as a share of GDP in any period since 1951′. This unprecedented slippage began as soon as the Tories took office in 2010, since which time the service has been forced to make tens of billions of pounds’ worth of cuts, or so-called ‘efficiency savings’, that have operated to corrode the quality of patient care across the board as well as the pay and morale of staff. And yet despite having met the ‘Nicholson challenge’ of £20 billion in cuts by 2015, NHS trusts continue to overspend as never before: owing largely to a ‘major budget squeeze’, the surplus left by the last Labour government swiftly collapsed into a deficit, which deepened twentyfold between 2013-4 and 2015-6 to nearly £2.5 billion, an apparently optimistic figure that experts say has been massaged by a ‘series of accounting devices’.
Late last year the National Audit Office (NAO), in finding that two-thirds of trusts were in the red, declared that the service’s ‘financial problems are endemic’ and — quelle surprise — that the situation is ‘not sustainable’. The Tory government responded by unsheathing a new and absurd ‘efficiency savings’ target of £22 billion by 2020, and went on to confirm that ‘real-terms NHS spending per person’ will drop sharply in the financial year 2018-9. Against this restatement of the austerity-imperative and per capita cut to the budget (perhaps the first such in NHS history), Theresa May’s at any rate misleading pledge of an extra £10 billion in investment by 2020 rings utterly hollow. That six consecutive years of brutal cuts have slashed billions from local authority social care budgets must also be mentioned at this juncture, for such cuts are helping to drive the rise in demand that has begun to overwhelm the health service under Tory rule.
Since 2010, no arm of the NHS has been able to escape the ravages of fiscal autophagia and the systematic under-funding of both health and social care. Primary care, for instance, ‘a service that has traditionally been seen as the jewel in the crown of the NHS’, saw its funding as a share of the total NHS budget decrease every year between 2010-11 and 2014-5 inclusive, despite a substantial increase in GPs’ workload over this period. Such a course of cutbacks led Professor Helen Stokes-Lampard, chair of the Royal College of General Practitioners, to warn that the ‘whole of general practice and primary care’ is ‘close to the precipice’.
And yet the government routinely seeks to blame GPs for the extreme difficulties facing accident and emergency departments, which are in fact overburdened partly as a result of cuts to social care but also because dozens of A&Es across the country have been either closed or downgraded since 2010. Analysing data for the third quarter of 2016-7, The King’s Fund found that the proportion of people waiting longer in A&E wards than the four-hour standard had ‘reached its highest level in more than a decade’, while annual figures for 2016 ‘show the number of patients stuck on trolleys in A&E units for more than 12 hours has doubled in two years, with a tripling in cases among the elderly.’ Such statistics, grave as they are, indicate a level of overcrowding that the Royal College of Emergency Medicine says is inimical to patient care and safety and which in January led nearly half of all hospital trusts to issue emergency alerts. And yet the Tories’ insistence on swingeing cuts mean that a further one in six A&E departments is slated for downgrade or closure.
Of course, the crisis in A&E has had damaging knock-on effects elsewhere, most notably for ambulance trusts. In January the NAO reported that the equivalent of 41,000 12-hour ambulance shifts were lost in 2015-6 due to turnaround at inundated A&E departments taking more than 30 minutes. This would have reduced even further the operational efficiency of services that are already under-staffed and under-funded and which have been since at least 2010, when the directive to make £75 million per annum in ‘efficiency savings’ was first laid down. It is therefore little wonder that the NAO charged two-thirds of ambulance trusts with failing to meet targets for responding to 999 calls on time in 2015-6. Nor should we be startled by the NHS Support Federation’s finding that cuts to social care and the inadequacy of ‘care of the elderly’ in general are relevant factors in the over-stretching of ambulance resources.
The Federation’s report on emergency ambulance services in England also implicated ‘shortcomings in mental health services’, which have themselves — according to one mental health charity — been ‘pushed to breaking point’ by ‘continuous cuts’ since 2010. Understanding as we do — in our heart of hearts — that ‘anxiety is the hegemonic affect of late capitalism’, it should come as no surprise to us that mental illness accounts for more than a quarter of the UK’s disease burden and as such is the ‘largest single source’ of that burden in this country. In 2012 a study by the London School of Economics noted that ‘nearly half of all ill health’ among under-65s is mental illness. In subsequent years report after report has suggested that the prevalence of such illness is increasing at a frightful rate, with one in 28 of us said to have been in contact with mental health services in 2014-5 alone. And yet in spite of all this the Tories have presided over what The King’s Fund has rather generously called a ‘notable reduction in funding to NHS mental health providers’. Indeed, the rhetoric of successive Tory governments on the need to deliver ‘parity of esteem’ for mental health has been brutally belied by their actions over the past seven years. Hence mental health trusts saw their budgets fall by more than 8 per cent in real terms between 2010-11 and 2014-5, with 40 per cent of trusts suffering cuts in 2015-6 and mental health units closing at a rate of knots all the while. The number of mental health nurses has dropped by nearly a sixth since 2010 because trusts ‘do not have enough money to employ as many as they need to provide proper care’. Fully ‘a third of children’s mental health workers say their service is facing cuts or closure’, according to a recent survey. Access to specialist treatment is grossly insufficient, especially for children, adolescents and new mothers, and waiting times for psychological therapy are so long that many of those who are referred for it end up self-harming or atttempting suicide. The wretchedness of this state of affairs, in which early intervention is commonly a fantasy, is reflected in the fact that detentions under the Mental Health Act have soared by 31 per cent since 2011.1
Lamentably common in the literature on cuts to mental health funding are expressions of concern over bed shortages. Thousands of mental health beds have been closed under Tory rule, with the numbers of vulnerable patients — especially children — ‘having to be sent out-of-area for care’ mounting year on year. The Royal College of Psychiatrists was not alone in condemning such shortages when it noted that at one point in 2014, not a single adult bed was free and available for use anywhere in the system. But of course, the attack on beds — which after all form the mainstay of health care provision in the UK — has extended far beyond the walls of psychiatric wards. 15,000 have been closed across the NHS since 2010, and today there exist particularly pronounced shortages in intensive care units — where doctors ‘are being forced to choose who lives and who dies’ — as well as in maternity units, which, under-funded as they are, were forced to close their doors on nearly 300 separate occasions in 2015-6. Moreover, bed occupancy across the whole of the service has climbed to dangerous levels, thanks in no small part to an epidemic of ‘bed-blocking’ brought about by cuts to social care. And so in 2016 a record number of life-saving operations had to be cancelled, with hospitals also forced to scrap more than 38,000 non-urgent elective procedures. Waiting lists, already at an eight-year high, were further augmented thus.
All in all, the cruelty and extent of Tory cuts to health and social care can simply not be fathomed. From the allocation of hearing aids and new drugs to the provision of contraceptive services and palliative care for children, it seems that every single aspect of the edifice has been under sustained assault from successive Tory governments. But we should do well to remember that it is not just patients who are suffering. NHS staff, one in eight of whom are foreign nationals, ensured that our health service was adjudged the top-performing system in the world as recently as 2014. And yet they continue to labour — unstintingly of course — under a pay cap imposed in 2010 that will have suppressed their income by 12 per cent in real terms by the end of this decade. Nurses are among those hardest hit, with many forced to turn to food banks, but the Royal College of Nursing, which is currently taking soundings from its 270,000 members on the possibility of industrial action, cannot plausibly expect the government to consider its demands: just a month ago Theresa May refused to look at lifting the cap, and last summer junior doctors, who were already gravely over-stretched, had an unsafe and unfair contract imposed upon them despite a campaign of resistance that included all-out strikes.
Of course, other elements of the workforce too are deeply unhappy: over-worked and endlessly scapegoated, our GPs are reported to be the most stressed in western Europe, and almost one in three expects to leave the health service in the next five years. Meanwhile, paramedics — dangerously busy, their training budgets having been slashed — are losing more days to work-related stress than ever before. But there has, perhaps, been no more outrageous display of the Conservatives’ contempt for those who strain to save our lives than their abolition last July of annual bursaries for student nurses and midwives. Applications to nursing and midwifery courses have nose-dived by 23 per cent as a result, and so we can say with some justification that the Tories directly intend to exacerbate the chronic under-staffing that is operating to compromise, in every NHS service, the welfare of staff and patients alike.
The question must be asked, then: to what end are the Tories dispensing all this misery? Why are they determined to destroy the NHS? Noam Chomsky once explained the ‘standard technique of privatization’ employed by governments hell-bent on waging class war: ‘defund, make sure things don’t work, people get angry, you hand it over to private capital’, for whom accumulation is, and will always be, Moses and the prophets. Suddenly the nefarious logic of Tory health policy since 2010 becomes screamingly apparent.
The brute facts are these. In 2012 the Tories’ Health and Social Care Act was passed, marking the ‘final stage in the conversion of the NHS into a market-based system’. In 2014-5, the second year after the HSCA came into force, privatisation increased by 500 per cent on the year before. In February 2016 it was reported by the NHS Support Federation that the private sector had been awarded ‘£5.5bn worth of NHS clinical contracts’ between April 2013 and January 2016 — ‘more than a third of the total value of contracts put out to tender’ in that time. These contracts, moreover, encompassed ‘every aspect of the patient journey’.
In light of the service’s financial woes — worsened to the tune of £10 billion per annum by the recurrent costs of running it as a market — it is certain that such outsourcing will only accelerate in coming years. This despite grave and legitimate concerns about the implications for the quality of patient care (vide the Hinchingbrooke calamity and any NHS contract to which the likes of G4S and Serco is a party). We can also expect demands for the large-scale introduction of patient charges to gain in volume. Already such calls have been heeded by GPs’ surgeries in some areas, where a ‘two-tier system’ is at risk of developing.
At any rate, we may say that the process of privatisation by stealth is in good hands. Simon Stevens, the chief executive of NHS England, has been called an ‘architect’ of the ‘neoliberalisation of NHS services’ that took place under Tony Blair, while the health secretary Jeremy Hunt (net worth: at least £10 million) once co-authored a book which recommended that the NHS be dismantled and replaced by an insurance-based system. Then there are the scores of mostly Tory MPs and peers with links to companies involved in private healthcare. Clearly it is neither in the nature nor the interests of these people to be or to stay wedded to the sacred founding principle of the NHS, namely that it should provide health care that is free at the point of delivery to anyone in need.
And so to the election. We simply cannot afford to reward the smug Hunt and his megalomaniacal boss by returning them both to Whitehall on June 8. 2016 was arguably the worst year in the history of the NHS, but a Tory victory in ten days’ time will portend a potentially fatal aggravation of the crisis in the shape of more cuts, more deaths and more privateering.2 This is just one of many reasons why the choice that awaits us next Thursday will be the starkest and most consequential such choice of our lifetimes to date.
Some will claim, on the basis of exponentially rising demand, that the NHS is doomed whichever party is in power. This ignores the fact that since 2010, Tory austerity has worked to feed demand with one hand and greatly diminish the capability of the service to manage it with the other. Some will continue to hold out hope that the Tories may one day ‘stop using the NHS as a political commodity and put patients’ needs first’. This, of course, is about as worthwhile as asking a flock of ravening vultures not to scavenge for its dinner. And many, no doubt, will cite the disastrous Private Finance Initiatives as evidence that the Labour Party cannot act responsibly qua custodian of the health service. Such criticisms as these, though, are utterly wrong-headed, for they overlook what we all understand: that a Labour government led by Corbyn will represent a sharp departure from the neo-Thatcherite regimes of Blair and Brown.
After all, as far as the NHS is concerned, Corbyn has put forth in Labour’s manifesto a fully costed funding commitment of £37 billion; he has set aside an additional £8 billion for the reversal of cuts to social care; he has pledged to repeal the HSCA; and he will, as one junior doctor noted, address the ‘social determinants of health’ — for example housing, employment and education — by putting an end to austerity in its wholeness.
Thus it does not — alas — seem unduly melodramatic to say that either we opt next week for Corbyn’s Labour or we face losing the NHS, as a public institution, for ever.
1. Of course, what makes Tory cuts to mental health services so sadistic is the fact that the context in which they are occurring — a mental health crisis of unprecedented proportions — has to a significant degree been shaped by Tory austerity as a whole. Two years ago Psychologists Against Austerity identified five so-called ‘austerity ailments’ whose profusion was linked to savage Tory cuts to various public services. Researchers from the Universities of Liverpool and Oxford have found that the introduction by the DWP of Work Capability Assessments ‘coincided with 590 “additional” suicides, 279,000 cases of mental illness and 725,000 more prescriptions for antidepressants’. Meanwhile child poverty and household food insecurity are on the rise; close to a million workers are employed on zero-hours contracts; and disabled people have, in the words of a UN committee, seen their rights ‘gravely and systematically violated’ by the Conservatives. Under such conditions it is inevitable that the Schrei der Natur, induced by that pandemic psychic pain which is endogenous to contemporary capitalism, should become louder and more piercing than ever before. As one mental health nurse put it three years ago, ‘[p]recarity is a machine for anxiety; austerity is a machine for making-vulnerable.’ At the levers of these machines, in their natural habitat, sit the Tories.
2. Indeed, the day after this post was published, Maytron signalled her intention to carry into effect the findings of the Naylor Report, which was published in March and which ‘calls for the disposal of NHS assets to the private sector, recommending that “inefficiently used” or unused NHS land and property should be sold to property developers.’