By Dr Rathi Guhadasan

On the NHS’s 77^th birthday, with Labour marking one year in government yesterday and Thursday’s publication of the “10-year plan”, what better time to give the NHS its own health check?

Ending the junior doctors’ strikes?

Certainly, removing the Tories’ boot from the neck of the NHS helped restore circulation initially. One of Wes Streeting’s first acts as Health Secretary was to settle the junior doctors’ (now renamed resident doctors) dispute, bringing over a year of industrial action to a close. However this required some goodwill on the part of the doctors, who made compromises for the promise of improvements to come, and it seems their patience has run out – the British Medical Association is currently balloting to strike again.

The workforce crisis

We still have over 100,000 vacancies in the NHS with increasing numbers of doctors and nurses leaving the service. Mental health issues are the main driver of staff absences and 30% reported experiencing burnout often or always. Public satisfaction with the NHS is at an all time low with lack of staff cited as a key reason for this. We need to urgently address pay and conditions across the NHS, to help improve retention and thereby make healthcare safer for staff and patients.

Replacing qualified doctors

Yet bizarrely, thousands of doctors are facing unemployment this year. The BMA has estimated 1,000 newly qualified GPs could be unemployed this summer and another 20,000 doctors could miss out on specialty training posts. And yet we continue to see the expansion of cheaper, less skilled Medical Associate Professionals, such as Physician Associates, both in number and scope, despite concerns from the medical profession and patients. This move is particularly attractive to the profit-driven private sector, who are now providing a lot of NHS care at taxpayers’ expense.

The Socialist Health Association’s sidelined motion to last year’s Labour Party conference called for an immediate recruitment freeze and phase out of these roles over two years, to be replaced with competency-based, appropriately regulated Medical Assistants. While we welcome the launch of the Leng review, with no interim emergency measures in place, doctors are left working in unsafe clinical environments and simultaneously losing training opportunities to these PAs. Frustrated at the General Medical Council’s continued failure to regulate PAs, the BMA has called for a new independent regulator for the medical profession.

As if replacing doctors with less qualified professionals wasn’t bad enough, we are now faced with the prospect of a “doctor in your pocket” – a digital app using AI-based algorithms. Technology can be a useful tool to aid skilled health professionals but cannot replace them. Doctors and other specialist health professionals are best placed to innovate and use technology as appropriate, to improve their services, and they can do that best when they are not overstretched and barely managing to cover essential services.

Added to this is the issue of digital poverty. Of households on a yearly income below £25,000, one in five don’t use the internet at all – this rises to one in three if those households include someone with a disability, and nearly half of those aged 65 years or older. In other words, those likely to experience the most health needs are also most likely to miss out unless this technology is matched with investment in targeted healthcare delivery for vulnerable groups.

Replacing the NHS itself

This happens by stealth.

Using private providers to deliver NHS elective care and bring down waiting lists was not introduced by this Labour government, but Wes Streeting has been vocal in his support for this strategy. Such privately provided services rely on NHS staff, leading to increased waiting times within the NHS – impacting those with more severe conditions or comorbidities who are not suitable for treatment by private providers.

Rather than ‘helping’ or adding to NHS services, these private providers are replacing them. We have also seen how mass private provision of cataract surgeries has left NHS ophthalmology units, which are the only source of potentially sight-saving and life-saving treatments for serious eye conditions, vulnerable to threat of closure. The NHS provides staff for these facilities, having borne the cost and burden of training them, and then deals with any treatment complications that may arise.

The NHS budget should not be used to fund the large profit margins demanded by these private companies, which are as high as 32% for cataract surgery providers. Outsourcing health services to the private sector is also associated with excess treatable mortality.

A moratorium on all further outsourcing of NHS services to the private providers is urgently needed, with a view to bringing all of these services in-house.

“…from hospital to community”

In Bevan’s NHS, we all had a neighbourhood GP, a local hospital which delivered essential services, including A&E and maternity, and then specialist services were available a little further away for those who needed them. The fractured services and delays we see today are as a result of stripping off the most profitable parts for the private sector and closing down the least profitable. We don’t need more urgent care centres – we need our local A&E’s back.

Shifting focus from hospital to community care could have positive outcomes for the population’s health, but only in the context of a fully supported hospital care system and with community services being fully staffed with appropriately skilled staff, fully resourced and fully publicly provided. It is vital that any building of new community services is not at the expense of secondary and tertiary care systems. In order to be effective, community and social care services need to be rebuilt in their own right, and not just used as a means of saving hospital costs.

“…a focus on prevention”

Prevention of ill health is a key long-term strategy, but the importance of genomics may be overstated. Research shows that almost 20% of deaths can be attributed to environmental and lifestyle factors, versus 2% from genetic ones. Significant investment into both primary and secondary prevention strategies is needed, with a fully funded public health service and targeted strategies such as Sure Start.

A real commitment to disease prevention will require a multisectoral effort. Lifting the two-child limit and benefit cap, and ensuring that low-income households, the disabled and other vulnerable groups are adequately supported will be essential to reduce poverty-related diseases. Strategies to make healthy foods accessible and affordable to low-income households are needed, with policy to directly tackle food multinationals whose products contribute to rising obesity and ill health. The impact of poor housing conditions on health, especially on children’s respiratory health, must be addressed urgently along with the rising threat of air pollution and climate change.

Meanwhile, a focus on prevention must not be an excuse to underfund the rest of NHS services which are so badly needed by the population.

What about delivery?

With the last chapter missing, this question looms over the entire report. Much has been promised, including ambulance fleets, diagnostics and other technology and new or refurbished community hubs, but the Health Secretary was uncharacteristically coy when asked how it would be funded.

The recent spending review did announce an additional £29 billion for the NHS over this Parliamentary term, but this is against a funding deficit over the last 15 years of over £400 billion. We know that there are currently £14 billion worth of repairs needed across the NHS and most staff are struggling on salaries which have not kept pace with inflation.

The risk is that this opens the door for more private investment into our NHS – when most Trusts are still paying back historic Private Finance Initiative debt, at an average rate of eight times the original investment – most having already cleared the capital amount. Overall, the NHS owes £44 billion in PFI debt. This could clear the repair backlog for most trusts and make other desperately needed improvements to our staff and services.

Diagnosis and prescription

The NHS is still Britain’s greatest achievement and saves countless lives every day. But, it needs urgent treatment.

We must bring all of its services back into public provision and fund it fully. To stop the catastrophic haemorrhaging of staff, we need fair pay and conditions for all workers now. And to ease the burden on the NHS, we need a publicly provided care service and intersectoral approach to public health and disease prevention.

Nye Bevan said of the NHS: “It will last as long as there are folk left with the faith to fight for it.” Today, we celebrate the NHS and all who work in it – but if we don’t act now, there will be nothing left to fight for.  

The Socialist Health Association has been promoting health and wellbeing through socialist principles since 1930. Join the fight to save the NHS here. Wes Streeting has received over £300,00 support from private healthcare. Support us to fight NHS privatisation here.

Dr Rathi Guhadasan is Chair of the Socialist Health Association.

Image: https://www.flickr.com/photos/nhse/9491399577 Copyright: A.J.Paraskos 07710 153546.Licence: Attribution 2.0 Generic CC BY 2.0 Deed